Comparative evaluation of postoperative pain and periapical healing after root canal treatment using three different base endodontic sealers - A randomized control clinical trial

The efficacy of premixed bioceramic sealers versus standard sealers on root canal treatment outcome, extrusion rate and post-obturation pain: A systematic review and meta-analysis

BACKGROUND

Limited evidence is available regarding the superior clinical properties of bioceramic sealers comparted with traditional standard sealers.

OBJECTIVES

This review aimed to answer the following research questions: 'In healthy patients requiring a root canal treatment (P), what is the efficacy of premixed bioceramic sealers (I) compared with traditional root canal epoxy resin-based sealers (C) in terms of survival, success rates (PICO1) sealer extrusion and resorption (PICO2) post-obturation pain (PICO3) (O)?'

METHODS

Authors independently searched three electronic databases: PubMed (including MEDLINE), Web of Science, Embase and Scopus up to 31 October 2023. This was accompanied by both grey literature and manual search. Detailed selection criteria were applied, namely mature permanent teeth requiring root canal treatment, premixed bioceramic sealer with gutta-percha as an intervention group, a standard filling technique as control group and full-text available in English. A random-effect meta-analysis was used to synthesize the body of evidence regarding the use of bioceramic sealers in root canal treatment and their impact on post-obturation pain. Effect sizes were represented as relative risks on a logarithmic scale for binary outcomes and as mean differences for continuous outcomes.

RESULTS

A total of 941 articles were identified. Fifteen Comparative clinical studies were finally included. Eleven were randomized clinical trials, and four were prospective clinical trials with control group. The follow-up of these studies was not greater than 2 years. No publication bias was observed in any study. No significant differences were observed between the two groups in terms of survival and success rates. A small non-significant lower risk of extrusion was observed for bioceramics. A small, non-significantly lower post-operative-pain within 24-h was observed when bioceramics were used.

DISCUSSION

The majority of current evidence shows inconsistencies in reporting and is of short-term duration. Robust prospective long-term trials are needed in this area to better support future recommendations.

CONCLUSION

This systematic review is the first to analyse several clinical outcomes using premixed sealers. Included studies differed in terms of clinical protocol and operator expertise, but reported a similar outcome when comparing bioceramic versus standard sealers. Tooth survival, treatment outcome, post-operative pain and periapical extrusion were similar and presented no significant differences between the two sealer types.

REGISTRATION

PROSPERO database (CRD42023449151).

Inflammatory response to bioceramic and epoxy resin-based endodontic sealers implanted in mice subcutaneous tissue: An in vivo study

To evaluate the inflammatory tissue response to BioRoot™ RCS (BR) and AH Plus Jet (AHPJ) sealers implanted in mice subcutaneous tissue. It was hypothesized that the inflammatory tissue response to BR would be milder than to AHPJ. An in vivo study was carried out using isogenic mice. The sealers were implanted during standardized surgical procedures. The inflammatory response was evaluated by microscopic analysis and von Kossa reaction in the reactionary tissue around the specimens after 7, 21, and 63 days. For comparisons, a zinc oxide and eugenol sealer (ZOE) was used as a positive control, in addition to a negative control without a sealer (n = 10 per group/period). All statistical analyses considered a significance level of 5%. All endodontic sealers triggered an inflammatory tissue response after 7 days. BR had a higher inflammatory cell count and a thicker fibrous capsule when compared with AHPJ, but both were less inflammatory than ZOE (p < .001). After 21 days, BR continued to trigger an intense inflammatory tissue response, higher in both microscopic parameters compared to AHPJ, and a thicker fibrous capsule than ZOE (p < .001). After 63 days, the inflammatory tissue response decreased in BR, matching the fibrous capsule thickness with AHPJ and ZOE. BR promoted intense calcium precipitation in all study periods. After 63 days, AHPJ and BR sealers were more biocompatible to subcutaneous mice tissue, but AHPJ present better early inflammatory response, as well as BR showed potential bioactivity. RESEARCH HIGHLIGHTS: The inflammatory tissue response triggered by a bioceramic endodontic sealer (BR) was not milder than that triggered by an epoxy-resin based endodontic sealer (AHPJ) during the first 3 weeks, considering the microscopic analysis of the reactionary tissue.

Postoperative pain after single-visit root canal treatments in necrotic teeth comparing instruments' kinematics and apical instrumentation limits - a prospective randomized multicenter clinical trial

OBJECTIVES

This prospective randomized multicenter clinical trial (PRMCT) investigated postoperative pain after single-visit root canal treatments in teeth affected by pulp necrosis (PN), and asymptomatic apical periodontitis (AAP) (with apical radiolucent areas) or normal periradicular tissues (without apical radiolucent areas) comparing different instruments' kinematics and apical instrumentation limits.

METHODS

Before chemomechanical preparation, 240 patients/teeth were randomly distributed into four groups (n = 60) according to the instruments' kinematics (rotary or reciprocating) and apical instrumentation limits (with or without intentional foraminal enlargement [IFE]). After that, specimens were submitted to the same irrigation and obturation techniques, and the patients were referred to undergo the definitive restorations. No medication was prescribed, but the patients were instructed to take either paracetamol (750 mg every 6 h for three days) or ibuprofen (600 mg every 6 h for three days) in pain cases. Postoperative pain incidence and levels were assessed at 24-, 48-, and 72 h following treatment completion according to a verbal rating scale (VRS) following a score. The Kolmogorov-Smirnov test was applied to assess the normality of the data. Mann-Whitney U, Chi-square, Friedman's ANOVA, and Friedman's multiple 2 to 2 comparison tests were employed to identify potential significant statistical differences among the variables in the study groups (P < .05).

RESULTS

Significant statistical differences were only observed among the groups considering tooth, periradicular status, and the occurrence of overfilling (sealer extrusion) (P < 0.00). Patients with teeth instrumented through rotary kinematics and without IFE experienced lower rates of postoperative pain; however, this difference was relevant only at 24 h (P < 0.05).

CONCLUSIONS

Postoperative pain was lower after using a rotary file system (Profile 04) inserted up to the apical constriction (AC). However, this finding was just statistically meaningful at 24 h.

TRIAL REGISTRATION

This PRMCT was approved by the Human Research Ethics Committee of the Paranaense University - UNIPAR, Francisco Beltrão, PR, Brazil (CAAE. 46,774,621.6.0000.0109) on 02/09/2021. It was registered at The Brazilian Registry of Clinical Trials - ReBEC (RBR-3r967t) on 01/06/2023, was performed according to the Principles of the Helsinki Declaration and is reported following the Consolidated Standards of Reporting Trials Statement.

Premixed calcium silicate-based root canal sealers have better biological properties than AH Plus: A systematic review and meta-analysis of in vivo animal studies and in vitro laboratory studies

Objectives

The aim was to determine whether premixed calcium silicate-based root canal sealers have better biological properties than AH Plus.

Materials and Methods

Searches of studies published up to January 2023 were performed in the PubMed/MEDLINE and EMBASE and via other methods (databases of the International Endodontic Journal, Journal of Endodontics, and gray literature). The inclusion criteria were in vivo animal and in vitro studies that analyzed the response in the dorsal subcutaneous tissue of rats, cell viability, and genotoxicity. Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias (RoB) tool for in vivo studies and modified CONSORT checklist for in vitro were appraised. Meta-analysis was performed using the Stata.

Results

Fifty-two studies were included. In the RoB, in vivo studies fulfilled 20%-50% of the items and in vitro 60%-100%. The studies included in the meta-analysis demonstrated better histocompatibility with the premixed calcium silicate-based sealers at 30 days and greater cell viability with these sealers when used in undiluted extracts in experimental period of 72 h and in extracts with 1:2 and 1:4 dilution in 24 and 72 h. In contrast, no difference between materials was found concerning genotoxicity.

Conclusion

Premixed calcium silicate-based root canal sealers have better histocompatibility and are less cytotoxic than the epoxy resin-based sealer AH Plus, demonstrating favorable biological behavior.

The status of clinical trials regarding root canal sealers

Objectives

This study aimed to present the results and analyses of clinical trials, including updates on the different functions of root canal sealers.

Materials and Methods

In June 2023, we performed a comprehensive search of ClinicalTrials.gov to identify interventional clinical trials pertaining to root canal sealers. In total, 23 clinical trials conducted up to June 2023 were included in this study.

Results

Approximately half of the trials (11 out of 23) were completed, while none were terminated or withdrawn. Each included trial had a minimum of 10 participants, with 11 trials having more than 100 participants. None of the assessed trials provided outcomes, and the majority (17 out of 23) lacked associated publications. In terms of geographic distribution, the USA and Canada did not contribute to any root canal sealer trials.

Conclusions

This study highlights the lack of diversity in trial locations, the absence of reported results, and a scarcity of clinical trials examining the physicochemical properties of different sealers. Most published trials primarily focused on assessing the post-operative pain effect of these sealers, but no significant difference was found regarding post-operative pain control.

Effect of an Experimental Resin-based Sealer (Resil) and AH-26 on Postoperative Pain: A Randomized Controlled Clinical Trial

Introduction

One of the most common problems in endodontic treatments is post-treatment pain, and sealers might be one of the factors influencing the degree of pain following root canal therapy. The purpose of this study is to compare pain following endodontic treatment using an AH-26 resin sealer against the Resil experimental sealer in mandibular molars with irreversible pulpitis.

Materials and Methods

One hundred patients with irreversible pulpitis in the mandibular first or second molar were randomly divided into two groups (n=50) based on the type of sealer applied. Two postgraduate students with at least five years of experience treated all patients. All patients had a single root canal treatment. Postoperative pain scores and analgesic consumption were assessed after 6, 12, 24, and 48 hours and 3, 4, 5, 6, and 7 days after the treatment. The data were statistically analyzed by Fisher's exact or Chi-Square test (to compare the distribution of qualitative variables in two groups), repeated measures ANOVA (to compare changes in pain intensity over time in two groups), Boneferronie (for pairwise comparisons), Friedman, Wilcoxon and Mann-Whitney tests (for assessment of the changes in pain scores over time). The generalized estimating equations (GEE) were used for assessing time and group effects.

Results

There was no significant difference in postoperative pain between groups at any of the time points studied (P>0.05), and also for patient analgesic consumption between groups (P>0.05). Both groups recorded the maximum pain levels in the first 6 hours. For each subsequent day postoperatively, the odds ratio (OR) of not using analgesics was 2.078.

Conclusion

Resil and AH-26 perform similarly in terms of the occurrence and intensity of postoperative pain in mandibular molar teeth with irreversible pulpitis.

Comparative antimicrobial activity of four different endodontic sealers

Dental cements are widely used in the clinical routine, specifically for root canal sealing. Within this context, it is expected that these materials present antimicrobial activity, since it would help in the prevention of apical and periapical infections. The present study aimed to comparatively verify the antimicrobial activity of four dental cements against microorganisms that are routinely isolated from endodontic infections. Reference strains of Enterococcus faecalis, Candida albicans and Escherichia coli were submitted to the agar diffusion test and to modified direct contact test using four different sealers: an eugenol zinc oxide compound, an epoxy resin associated to calcium hydroxide and bismuth, a mineral trioxide aggregate (MTA) and a bioceramics. Different E. coli, C. albicans and E. faecalis growth inhibition profiles were observed in the agar diffusion assay. In the direct contact test, the bioceramics presented a higher microbicide activity on all microorganisms tested herein. Dental cements have different antimicrobial activities, being that the bioceramics present the most consistent antimicrobial activity, and that the direct contact test presented more uniform results than the agar diffusion test. This study reveals the antimicrobial activities of different cements and allow dentists to decide which material to employ in their daily practice.

A Systematic Review on Comparison of Periapical Healing and Post-Operative Pain between Bioceramic and Epoxy Resin Based Sealers

To compare the incidence of postoperative discomfort and periapical healing in endodontically treated teeth following the use of resin-based or bioceramic sealers. In vivo, clinical trials were included in the study. The selection criteria, data extraction, and analysis were performed to evaluate the quality and publication bias of the selected studies. The primary outcome measure was the comparison of postoperative discomfort between the two sealer types. Seven studies were included in the systematic review, with a modest level of evidence found in the quality assessment. There are no significant differences in the postoperative discomfort levels between resin-based and bioceramic sealers. However, the overall quality of the clinical trials was moderate, highlighting the need for further well-designed clinical trials with appropriate measures of randomization, allocation concealment, and blinding to establish a definitive conclusion on the incidence of Postoperative discomfort associated with the use of these sealers.

Periapical Healing following Root Canal Treatment Using Different Endodontic Sealers: A Systematic Review

The healing of the periapical tissues is crucial to the success of root canal treatment. The review studies effectively examine various endodontic root canal sealants in terms of periapical healing. This systematic review was formulated following the PRISMA 2020 guidelines and registered in the international prospective register of systematic reviews (PROSPERO) number-CRD42021239192. To find relevant articles, PubMed Central and Medline databases (until February 2022) were searched. Studies that evaluated healing following the application of different endodontic sealers were analysed. A primary outcome measure was the resolution of periapical lesions following the endodontic treatment. In vivo studies comparing radiographic treatment outcomes and articles with a minimum of 6-month follow-up were included. A total of 9 clinical trial studies that met all the inclusion criteria were included in the analysis. The overall risk of bias was high in four studies out of nine studies. Periapical lesions showed significant healing after endodontic treatment regardless of sealer type, although bioceramic and bioactive sealers had shown better results.

A comprehensive in vitro comparison of the biological and physicochemical properties of bioactive root canal sealers

OBJECTIVES

To evaluate the biological and physicochemical features of bioactive root canal sealers.

MATERIALS AND METHODS

Human periodontal ligament fibroblasts (hPDLF) and human osteoblasts (hOB) were exposed to eluates of three bioactive root canal sealers, GuttaFlow® bioseal (GF), BioRoot™ RCS (BR), and TotalFill® BC Sealer (TF), and the epoxy resin-based sealer AH plus® (AH). Cytotoxicity and cellular inflammatory response were evaluated. The osteogenic potential was examined using human mesenchymal stem cells (hMSC). Film thickness, flowability, and pH were assessed. Root canal treatment was performed on human extracted teeth to evaluate the sealers' tightness towards bacterial penetration. The antibacterial activity against common pathogens in primary root canal infections was tested.

RESULTS

AH was severely cytotoxic to hPDLF and hOB (p < 0.001). The bioactive sealers were generally less cytotoxic. IL-6 levels in hPDLF were elevated in the presence of AH (p < 0.05). AH and GF suppressed IL-6 production in hOB (p < 0.05). AH and BR stimulated the PGE₂ production in hPDLF and hOB (p < 0.05). BR was the only sealer that led to calcium deposits in hMSC (p < 0.05). TF and AH showed the lowest film thickness and the highest flowability. Bacterial tightness was best in teeth filled with AH and BR. All sealers showed similar antimicrobial activity, but the overall antimicrobial efficacy was moderate as the bacteria were reduced by just one log scale (p < 0.05).

CONCLUSIONS

This study revealed favorable in vitro results regarding the biocompatibility of the bioactive root canal sealers.

CLINICAL RELEVANCE

Bioactive root canal sealers may be a useful alternative to epoxy resin-based sealers.