The Journal of EVIDENCE-BASED DENTAL PRACTICE

ORIGINAL ARTICLE

DISLODGMENT RESISTANCE OF
BIOCERAMIC AND EPOXY SEALERS: A
SYSTEMATIC REVIEW AND META-ANALYSIS

EMMANUEL JOÃO NOGUEIRA LEAL SILVA, DDS, MSc, PhDa,b,c,

ANTONIO CANABARRO, DDS, MSc, PhDd,
MÁRCIA REJANE THOMAS CANABARRO ANDRADE, DDS, MSc, PhDe,
DANIELE MOREIRA CAVALCANTE, DDS, MSc, PhDc, OSCAR VON STETTEN, DDSf,
TATIANA KELLY DA SILVA FIDALGO, DDS, MSD, PhDg, AND
GUSTAVO DE-DEUS, DDS, MS, PhDc
a
Department of Endodontics, School of Dentistry–Grande Rio University (UNIGRANRIO), Duque de Caxias, RJ, Brazil
b
Department of Endodontics, Rio de Janeiro State University (UERJ), Rio de Janeiro, RJ, Brazil
c
Department of Endodontics, Fluminense Federal University (UFF), Niterói, RJ, Brazil
d
Department of Periodontology, Veiga de Almeida University (UVA), Rio de Janeiro, RJ, Brazil
e
Department of Paediatric Dentistry, Fluminense Federal University (UFF), Nova Fibrurgo, RJ, Brazil
f
Private Practice Limited to Endodontics, Stuttgart, Germany
g
Department of Preventive and Community Dentistry, Rio de Janeiro State University (UERJ), Rio de Janeiro, RJ, Brazil

ABSTRACT CORRESPONDING AUTHOR:

Emmanuel João Nogueira Leal Silva,
Objectives Dental School, Grande Rio University
The aim of the present systematic review was to evaluate if epoxy resin–based -UNIGRANRIO Endodontics Department
root canal sealers present superior push-out bond strength compared to cal- Rua Herotides de Oliveira, 61/902 Icaraí,
cium silicate–based root canal sealers. Niterói, RJ, Brazil.
E-mail: nogueiraemmanuel@hotmail.com

Methods
The inclusion criteria consisted of in vitro studies that compared the push-out KEYWORDS
bond strength of epoxy resin–based and calcium silicate–based sealers. A sys- Dental cements, Endosequence,
tematic search was performed in the following databases for articles published MTA, Push-out bond strength,
Systematic review, Root canal sealers
until February 2018: PubMed, ScienceDirect, Scopus, Web of Science, and
OpenGrey. The quality assessment and data extraction of the selected articles
were performed. A meta-analysis of the pooled data and the subgroups ac-
cording to the root thirds was carried out using the RevMan software (P , .05). Conflict of Interest: The authors have
stated explicitly that there are no
Results conflicts of interest in connection
The search resulted in 2292 studies. After the duplicate studies were removed with this article.
and the title and abstract were read, 20 studies were selected and 17 were Source of Funding: None.
considered as having a low risk of bias. The pooled meta-analysis comparing
epoxy resin–based (n 5 467) and paste-to-paste calcium silicate–based root canal Received 12 January 2019; revised
sealers (n 5 467) demonstrated higher mean push-out bond strength values (P , 10 March 2019; accepted 12 April
.001) for the epoxy resin–based root canal sealers; the heterogeneity among 2019
studies was 85% (I2). The comparisons between epoxy resin–based (n 5 358) and J Evid Base Dent Pract 2019: [1-15]
premixed ready-to-use calcium silicate–based root canal sealers (n 5 358) also
1532-3382/$36.00
demonstrated a significant difference between the sealers (P , .05), with an I2 of
ª 2019 Elsevier Inc.
95%. The subgroup analysis showed that only in the middle third, were increased
All rights reserved.
bond strength values for epoxy resin–based sealer observed (P , .001), with an I2 doi: https://doi.org/10.1016/
of 94%. j.jebdp.2019.04.004

- 2019 1
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Conclusions
The epoxy resin–based sealer demonstratedhigher push-
out bond strength than paste-to-paste calcium silicate–
based root canal sealer regardless of the root third
assessed. In addition, the epoxy resin–based sealer exhibi-
ted increased push-out bond strength in comparison with
premixed ready-to-use calcium silicate–based root canal
sealer when evaluating the middle third.
INTRODUCTION
M ineral trioxide aggregate (MTA) is a Portland cement–
derived hydraulic material that has been widely used
in a variety of applications in endodontics as supported by
an extensive body of clinical and experimental evidence.1–3
The performance of MTA is supported by the interplay be-
tween its optimal physical and biological properties such as
biocompatibility, bioactivity, and sealability.4 In fact, the
combination of its biocompatibility, the antibacterial
environment it creates, and its ability to form apatite-like
crystalline precipitates on its surface in conjunction with
the tissue fluid may contribute to its success in clinical
procedures.5–8 However, MTA does not exhibit the physical
properties required to be used as a root canal sealer, which
produced an important gap in its clinical applications.
Moreover, the use of MTA cement as endodontic sealer
could be limited by the impossibility to perform, when
necessary, a retreatment. This context leads to increasing
efforts toward the creation of a close-to-ideal MTA-based
sealer with exclusive balance between its biological and
physicochemical characteristics3 to recreate the
performance of MTA but inside the canal space.
Several root canal sealers, such as paste-to-paste calcium
silicate–based root canal sealer MTA Fillapex (Angelus,
Londrina, Brazil) and premixed ready-to-use calcium
silicate–based root canal sealer EndoSequence BC Sealer
(Brasseler, Savannah, GA), which is also commercialized as
Total Fill BC Sealer or iRoot SP, have been launched in the
endodontic market as examples of calcium silicate–
containing root canal sealers, or merely bioceramic
sealers. These products promise improved physical-
chemical properties when compared with conventional
MTA.9 According to the manufacturers, these sealers benefit
from MTA’s bioactivity, allowing interaction with dentin and
causing intratubular calcium and silicate incorporation and
formation of tag-like structures,10 enhancing the adhesion
and sealing ability of the root fillings. However, the
performance of these bioceramic sealers is still under
scientific scrutiny.
Push-out tests have often been used in endodontic research
to rank the quality of the root-filling materials and tech-
niques and also as a surrogate for the sealing ability, mainly
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of root canal sealers, driven by the growing interest in
creating an effective bonded interface between the core
filling material and root dentin. With this background, me-
chanically bonded interface assays have been observed to
provide a better understanding of the quality of the root-
filling procedure and outcome expectation.11–14 This
outcome is undoubtedly influenced by several variables,
including the root canal sealer.12–17
Owing to the contradictory findings available in the litera-
ture,11–17 a systematic review and meta-analysis was con-
ducted with the aim of answering the following focused
question: “Do calcium silicate–based root canal sealers
present a superior push-out bond strength compared to
epoxy resin–based ones?”
METHODS
Protocol and Registration
This systematic review was registered on the Prospero
database under the number CRD42016027491 and was
conducted following the recommendations of the Preferred
Reporting Items for Systematic Review and Meta-Analysis
(PRISMA) guidelines.18
Search Strategy
The search process was performed independently by 2 ex-
aminers (E.J.L.N.S. and T.K.d.S.F.). The electronic databases
PubMed, ScienceDirect, Scopus, Web of Science, and
OpenGrey were searched for articles published until
February 2018, without language or year restrictions. The
electronic search strategy was developed using the most
cited descriptors in previous publications on this theme,
combining Medical Subject Headings (MeSH) terms and text
words. For each database, the following terms were com-
bined: “dental cement*,” “epoxy resins,” “root canal seal-
ants,” “root canal seal*,” “epoxy resin-based root canal
sealer,” “resin-based root canal,” “epoxy resin sealer,”
“bioceramic sealer,” “bioceramic root canal,” “calcium sili-
cate sealer,” “calcium silicate cement*,” “MTA seal*,” “root
canal fill*,” “push-out,” “push-out bond strength,” “bond
failure,” “biomechanical responses,” and “dislodgement
resistance.” The Boolean operators “AND” and “OR” were
applied to combine the terms and create the search strategy.
The search strategies defined for each database are detailed
in Table 1. A complementary screening of the references of
the selected studies was performed to find any additional
studies that did not appear in the primary database
search. Articles from different sources were imported
into the EndNote Web Reference Manager (EndNote
Web Reference Manager (Thomson Reuters, Philadelphia,
PA) to catalog the references and automatically remove
duplicate records.
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

Table 1. Search strategy in the databases.

Database Search strategy

PubMed #1 (((((((((((((((((dental cements[MeSH Terms]) OR epoxy resins[MeSH Terms]) OR root canal sealants
[MeSH Terms]) OR dental cement*[Title/Abstract]) OR epoxy resins[Title/Abstract]) OR root canal seal*
[Title/Abstract]) OR endodontic seal*[Title/Abstract]) OR epoxy resin-based root canal sealer[Title/
Abstract]) OR resin-based root canal[Title/Abstract]) OR epoxy resin sealer[Title/Abstract]) OR
bioceramic sealer[Title/Abstract]) OR bioceramic root canal[Title/Abstract]) OR calcium silicate sealer
[Title/Abstract]) OR calcium silicate cement*[Title/Abstract]) OR MTA seal*[Title/Abstract]) OR MTA
cement*[Title/Abstract]) OR root canal fill*[Title/Abstract]

#2 ((((Push-out[Title/Abstract]) OR push-out bond strength[Title/Abstract]) OR bond failure[Title/

Abstract]) OR biomechanical responses[Title/Abstract]) OR dislodgement resistance[Title/Abstract]

# 1 and # 2

Scopus #1 TITLE-ABS-KEY(epoxy resins) OR TITLE-ABS-KEY(root canal sealants) OR TITLE-ABS-KEY(root canal

seal*) OR TITLE-ABS-KEY(endodontic seal*) OR TITLE-ABS-KEY(epoxy resin-based root canal sealer)
OR TITLE-ABS-KEY(resin-based root canal) OR TITLE-ABS-KEY(epoxy resin sealer) OR TITLE-ABS-
KEY(bioceramic sealer) OR TITLE-ABS-KEY(bioceramic root canal) OR TITLE-ABS-KEY(calcium silicate
sealer) OR TITLE-ABS-KEY(calcium silicate cement*) OR TITLE-ABS-KEY(MTA seal*) OR TITLE-ABS-
KEY(MTA cement*) OR TITLE-ABS-KEY(root canal fill*)

#2 TITLE-ABS-KEY(push-out) OR TITLE-ABS-KEY(push-out bond strength) OR TITLE-ABS-KEY(bond

failure) OR TITLE-ABS-KEY(biomechanical responses) OR TITLE-ABS-KEY(dislodgement resistance)

# 1 and # 2

Web of Science #1 TS5(“dental cement*” OR “epoxy resins” OR “root canal sealants” OR “root canal seal*” OR
“epoxy resin-based root canal sealer” OR “resin-based root canal” OR “epoxy resin sealer” OR
“bioceramic sealer” OR “bioceramic root canal” OR “calcium silicate sealer” OR “calcium silicate
cement*” OR “MTA seal*” OR “root canal fill*”)

#2 TS5(“push-out” OR “push-out bond strength” OR “bond failure” OR “biomechanical responses”

OR “dislodgement resistance”)

#1 and #2

ScienceDirect #1 TITLE-ABS-KEY(dental cement*) OR TITLE-ABS-KEY(epoxy resins) OR TITLE-ABS-KEY(root canal

sealants) OR TITLE-ABS-KEY(root canal seal*) OR TITLE-ABS-KEY(endodontic seal*) OR TITLE-ABS-
KEY(epoxy resin-based root canal sealer) OR TITLE-ABS-KEY(resin-based root canal) OR TITLE-ABS-
KEY(epoxy resin sealer) OR TITLE-ABS-KEY(bioceramic sealer) OR TITLE-ABS-KEY(bioceramic root
canal) OR TITLE-ABS-KEY(calcium silicate sealer) OR TITLE-ABS-KEY(calcium silicate cement*) OR
TITLE-ABS-KEY(MTA seal*) OR TITLE-ABS-KEY(MTA cement*) OR TITLE-ABS-KEY(root canal fill*)

#2 TITLE-ABS-KEY(push-out) OR TITLE-ABS-KEY(push-out bond strength) OR TITLE-ABS-KEY(bond

failure) OR TITLE-ABS-KEY(biomechanical responses) OR TITLE-ABS-KEY(dislodgement resistance)

# 1 and # 2

OpenGrey - SIGLE #1 dental cement* OR epoxy resins OR root canal sealants OR root canal seal* OR endodontic seal* OR
epoxy resin-based root canal sealer OR resin-based root canal OR epoxy resin sealer OR bioceramic
sealer OR bioceramic root canal OR calcium silicate sealer OR calcium silicate cement* OR MTA seal*
OR MTA cement* OR root canal fill*

#2 push-out OR push-out bond strength OR bond failure OR biomechanical responses OR

dislodgement resistance

# 1 and #2

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 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Eligibility Criteria
In vitro studies that evaluated the shear bond values of
epoxy resin–based sealers compared with calcium silicate–
based ones were included. The eligibility criteria were
based on the population-intervention-comparison-
outcomes (PICO) strategy18 as follows:
⁃ P: extracted mature human teeth.
⁃ I: calcium silicate sealers.
⁃ C: resin-based sealers.
⁃ O: push-out bond strength values.
Studies that used different instruments or methods of root
canal preparation and filling protocols for the comparisons
groups were excluded. In addition, reviews, letters, opinion
articles, conference abstracts, studies performed in animals,
studies that included artificial teeth, and studies that did not
provide or in which it was not possible to recover the mean
and standard deviation of the push-out bond strength
values were excluded.
Selection of the Studies
Two authors (E.J.N.L.S. and T.K.d.S.F) independently
selected the retrieved studies by examining the titles and
abstracts. The full text was accessed when it was not
possible to judge the studies by the title and abstract. The
second stage consisted of reading the full texts and judging
the potential studies to be included based on the eligibility
criteria through the PICO strategy. Disagreements on the
inclusion of studies were resolved by consensus with a third
author (G.D.). Duplicate studies in the database searches
were considered only once.
Data Extraction
Two authors (E.J.N.L.S. and T.K.d.S.F.) independently
collected the data from the included studies. Disagree-
ments were solved by a third author (G.D.). Information
regarding the publication (author and publication year),
teeth type, root third, sample size, instrumentation protocol,
irrigants, root-filling material, characteristics of mechanical
test, push-out bond strength values, and statistical analysis
was extracted. In cases of missing data, the authors were
contacted 3 times by electronic message. When the authors
did not answer, the study was excluded from the meta-
analysis.
Quality Assessment
Each selected study was evaluated for the inner methodo-
logical risk of bias independently by 2 authors (E.J.N.L.S.
and T.K.S.F.) according to the previously published system-
atic reviews of in vitro studies.19–21 A quality assessment
with adaptations used in previously published systematic
reviews performed with in vitro studies was adopted.19,20
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For the quality assessment of the included studies, the
following parameters were considered: (1) sample size
calculation, (2) samples with similar dimensions, (3) stan-
dardization of instrumentation procedures, (4) standardiza-
tion of filling procedures, (5) statistical analysis carried out,
and (6) risk of bias.
The power of the studies was calculated based on the push-
out bond strength means, standard deviations, and sample
size for each group of teeth. The power analysis is able to
measure the effect size that can be detected using a given
sample size. For this purpose, a confidence interval of 95%
was adopted and a 2-tailed test was conducted using
OpenEpi 3.04.04 software (University of Emory, Atlanta,
GA). Each parameter for all the included studies was judged
as “low,” “high,” or “unclear” risk of bias. During the quality
assessment, in the case of disagreements between authors,
the disagreements were resolved through a discussion with
a third author (G.D.). When any parameter was judged as
“unclear,” the author was contacted by an electronic mes-
sage to obtain more information and to enable the judg-
ment of “low” or “high” risk of bias.
Meta-analysis
The quantitative analysis was carried out on the studies that
provided or in which it was possible to recover the mean,
standard deviation of the push-out bond strength values,
and the number of specimens per group used. The meta-
analysis was performed using the RevMan software
(version 5.2; the Nordic Cochrane Centre, the Cochrane
Collaboration, 2012, Copenhagen, Denmark). The random-
effect model was used because the studies did not have the
same methodology. The standard mean difference in the
shear bond strength values (MPa) between the groups was
obtained from the studies, and the results of the meta-
analysis were presented in a forest plot. The heterogeneity
among the studies was tested through the Higgs index (I2),
and a forest plot was generated for these comparisons.
RESULTS
Selection of Studies
Figure 1 shows the flow diagram of the search strategy.
Initially, the search resulted in 2292 published studies,
which consisted of 768 from PubMed, 1026 from Scopus,
141 from Web of Science, 355 from ScienceDirect, and 2
from OpenGrey. A total of 588 duplicate studies were
excluded. The analysis of titles and abstracts resulted in
the exclusion of 1672 of the published studies, leaving 22
for full-text reading.11–17,22–35 The main reason for the
rejection of the articles was that the tested groups did not
meet the inclusion criteria. After comprehensive reading, 2
studies were excluded because different root canal
filling methods were performed among the groups.15,25

Figure 1. Flow diagram of the literature search and included studies.
Thus, 20 studies were selected for this systematic re-
view.11–14,16,17,22–24,26–31,33–36 After the electronic search,
the references of the selected studies were hand searched,
but no further articles were found.
Data Collection
The data collected from the 20 included studies are sum-
marized in Table 2. The sample size calculation was
performed only in the studies by Carvalho et al.,11
Oliveira et al.,28 Silva et al.,21 and Wiesse et al.17 All
included studies performed the load using a plunger until
bond failure occurred. Moreover, all included studies
reported the push-out bond strength in megapascals
(MPa) using the following formula: MPa 5 maximum load
(N)/adhesion area to dentin (mm2). Eleven studies evaluated
the push-out bond strength from the anterior teeth sli-
ces.11,13,17,22,24,27–29,31,34,36 All the included studies used
NaOCl as an irrigant and ethylene diamine tetraacetic acid
(EDTA) as a chelating agent. Other irrigation protocols, such
as the use of different chelating agents11 or the use of
The Journal of EVIDENCE-BASED DENTAL PRACTICE
chlorhexidine,30 were also used in the studies by Carvalho
et al. and Razmi et al.; however, it was decided to include
only the NaOCl/EDTA protocol because it is the most
accepted protocol in endodontic therapy.37 The slices
varied from 1.0 mm to 4.0 mm,36 and the speed of push-
out assay varied from 0.5 mm/min11,13,16,17,23,24,26,27,34–36
to 1 mm/min.12,14,22,28,29,31,33 Among the studies that
compared AH Plus (Dentsply Sirona, Ballaigues, Switzerland)
and MTA Fillapex, 16 demonstrated a higher push-out bond
strength (P , .05) for the AH Plus sealer.12–14,17,22–24,26–
29,31,33–35,38
In addition, no differences were observed be-
tween the AH Plus and EndoSequence BC Sealer (P . .05),
except in the middle third where increased bond strength
values for the AH Plus sealer were observed (P , .05).
Risk of Bias
Regarding the evaluation of the inner methodological risk of
bias, 17 studies were considered as having a “low” risk of
bias and 3 studies were considered as having a “moderate”
risk of bias.12,14,16 The final methodological risk of bias
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The Journal of EVIDENCE-BASED DENTAL PRACTICE

Table 2. Summarized data collected from the selected studies.

Mechanical Calcium
Tooth/ Root canal test and Epoxy resin, silicate,
Author, y sample (n) preparation Irrigant root third mean 6 SD mean 6 SD Power analysis Statistical analysis

Amin et al., Maxillary incisor - 15 K-files - 5 mL of 2.5% NaOCl - 2-mm-thick slices AH Plus 4.26 6 2.8 iRoot SP AH Plus x iRoot SP: Two-way ANOVA and
2013 n 5 10 - ProTaper rotary - 5 mL of 17% EDTA for - 1 mm/min 0.86 6 0.53 96.45% Tukey P , .05
system 1 minute followed by 5 mL - Plunger with MTA Fillapex AH Plus x
of distilled water 0.7 mm 1.21 6 1.07 MTA Fillapex: 89.58%
- Middle third

Araujo et al., Maxillary - 15 K-files - 2 mL of 2.5% NaOCl - 1-mm-thick slices AH Plus WaveOne: MTA Fillapex Data not supported ANOVA and Tukey
2016 canines - Reciproc and - 5 mL of 17% EDTA for 5 min - 0.5 mm/min –
0.67 (CI: 0.58 0.77) WaveOne: P , .05
n 5 not WaveOne systems and 10 mL of distilled water - Plunger with 0.6, Reciproc: –
0.69 (CI: 0.59 0.78)
informed - Lateral 0.4, and 0.25 mm –
0.77 (CI: 0.64 0.91) Reciproc:
compaction - 3 thirds Lateral compaction: –
0.56 (CI: 0.48 0.64)
technique –
2.42 (CI: 2.13 2.70) Lateral compaction:
- ProTaper Universal –
1.71 (CI: 1.52 1.90)
rotary system

Carvalho et al., Mandibular - ProTaper System 1% sodium hypochlorite, and - 1.5-mm-thick AH-Plus 16.29 6 2.56 EndoSequence: AH Plus x t-test: P , .05
2017a premolars (Dentsply subsequent smear layer slices 9.48 6 1.72 EndoSequence: 100%
n 5 48 Maillefer, removal with 5 mL of 17% EDTA - 0.5 mm/min
Ballaigues, for 3 min - Middle third
Switzerland)

Carvalho et al., Maxillary Artificial holes - Dentine slices were - 1.0-mm-thick AH Plus 13.04 6 7.15 MTA Fillapex: AH Plus x Kruskal-Wallis:
2017b incisors immersed in a 2.5% sodium slices 0.39 6 0.50 MTA Fillapex: P , .05
n 5 90 hypochlorite (NaOCl) - 0.5 mm/min Total Fill BC: 100%
solution for 15 min - Plunger with 6.65 6 4.18 AH Plus x
- Immersion in bidistilled 0.6 mm Total Fill BC:
water - Middle third 100%
- 17% EDTA, 2.25% PA, or
10% CA, each applied for
3 min.
- Distilled water followed by
2.5% NaOCl for 1 min and
bidistilled water for 1 min.

Chávez-Andrade Maxillary canines - ProTaper rotary - 5 ml of 2.5% NaOCl - 2.0-mm-thick AH Plus Cervical: MTA Fillapex AH Plus x ANOVA and Tukey
et al., 2013 n 5 10 instruments between each instrument. slices 5.03 6 1.87 Cervical: MTA Fillapex test: P , .05
- 5 ml of 17% EDTA for - 0.5 mm/min Middle: 1.21 6 0.42 Cervical:
1 minute, followed by - 3 thirds 3.65 6 1.53 Middle: 100%
10 ml of 2.5% NaOCl Apical: 1.22 6 0.41 Middle:
10.15 6 4.36 Apical: 99.81%
1.19 6 0.56 Apical:
100%

(continued )
 Ersahan et al., Maxillary canines Artificial holes - 5 mL of 5.25% NaOCl - 4-mm-thick slices AH Plus 1.99 6 1.33 iRoot AH Plus x iRoot ANOVA P , .001
2010 n 5 30 followed by 5 mL of 17% - 0.5 mm/min 1.32 6 0.83 98.42%
- EDTA to remove the smear - Plunger with
layer and then 10 mL of 1.7 mm
distilled water - 3 thirds

Gokturk et al., Single-rooted Reciproc rotary 5 mL of 2.5% NaOCl, 5 mL of - 2-mm-thick slices AH Plus 2.03 6 1.24 MTA Fillapex AH Plus x ANOVA and
2017 mandibular premolars instruments to 17% EDTA, and 5 mL distilled - 0.5 mm/min 1.75 6 1.07 MTA Fillapex: Tamhane
n 5 10 a size R50 water under sonic agitation - Plunger with 90% 7.61% P , .05
of filling material
area
- 3 thirds

Guiotti et al., Canines n 5 10 #15 K-file enlarged - 2.5% sodium hypochlorite - 2-mm-thick slices AH Plus Cervical: MTA Fillapec AH Plus x ANOVA and Tukey
2014 to a #25 K-file solution - 0.5 mm/min 5.03 6 1.87 Cervical: MTA Fillapex tests
- 17% EDTA - Plunger with Middle: 1.21 6 0.42 Cervical: P , .05
- Distilled water 1.3 mm 3.65 6 1.53 Middle: 100%
- 3 thirds Apical: 0.90 6 0.24 Middle:
10.15 6 4.36 Apical: 99.99%
1.19 6 0.56 Apical:
100%

Nagas et al., Single-rooted n 5 25 ProTaper rotary files - 10 mL of 5.25% sodium - 1-mm-thick slices Not informed Not informed Data not supported P , .05:
2012 hypochlorite (NaOCl) - 1 mm/min iRoot SP . AH
- 17% EDTA for 1 minute - 3 thirds Plus . Epiphany .
- 10 mL of distilled water MTA Fillapex

Oliveira et al., Maxillary canines Middle third of - 5.25% NaOCl for 10 min. - 1-mm-thick slices AH Plus 44.32 6 13.00 MTA Fillapex Mann-Whitney with
2016 n 5 60 the roots was - 2.5% NaOCl for 15 min - 1 mm/min 3.41 6 2.51 Bonferroni correction
enlarged using - 17% EDTA for 3 min - Middle third iRoot P , .05
Gates Glidden 14.36 6 6.47

Paula et al., Maxillary canine Reciproc system - 1% sodium hypochlorite. - 2-mm-thick slices AH Plus 1.39 6 0.60 MTA Fillapex AH Plus x Three-way ANOVA
n 5 13 0.76 6 0.34 P , .05

The Journal of EVIDENCE-BASED DENTAL PRACTICE

2016 - 5 mL of 17% EDTA for 3 min - 1 mm/min MTA Fillapex
- 5 mL of distilled water - 3 thirds 90.89%

Razmi et al., Single-rooted ProTaper rotary - 10 mL of 5.25% NaOCl - 2-mm-thick slices NaOCl/AH Plus: NaOCl/ AH Plus x Three-way ANOVA,
2016 extracted human instruments - 10 mL of 17% EDTA - 1 mm/min Dry EndoSequence: EndoSequence post hoc tests, t-test,
premolars n 5 12 - 20 mL of saline - middle third 1.66 6 0.08 Dry Dry and the Fisher exact
Final irrigation: Half wet 1.22 6 0.21 100% test.
5.25% NaOCl or 2% 0.20 6 0.45 Half wet Half-wet
chlorhexidine Wet 1.28 6 0.63 99.80%
0.48 6 0.27 Wet Wet
0.71 6 0.24 59.70%

(continued )
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Table 2. (continued)

Mechanical Calcium
Tooth/ Root canal test and Epoxy resin, silicate,
Author, y sample (n) preparation Irrigant root third mean 6 SD mean 6 SD Power analysis Statistical analysis

Sagsen et al., Maxillary incisor ProTaper rotary - 5 mL of 2.5% NaOCl - 1-mm-thick slices AH Plus Cervical MTA Fillapex AH Plus x ANOVA and the post
2011 n 5 10 instruments - 5 mL of 17% EDTA 1.9 6 0.55 Cervical MTA Fillapex hoc
- 1 mm/min Middle 0.8 6 0.55 Cervical Holm-Sidak test
- Distilled water
- Plunger with 1.0, 2.9 6 1.1 Middle 99.40% P , .05
0.5, and 0.3 mm Apical 1.37 6 1.0 Middle Middle and apical
- 3 thirds 2.9 6 1.0 Apical 90.23% MTA , AH Plus and
0.6 6 0.38 Apical iRoot
iRoot SP 100%
Cervical AH Plus x iRoot
1.52 6 0.53 Cervical
Middle 34.95%
2.58 6 1.25 Middle
Apical 8.69%
2.6 6 2.34 Apical
5.26%

Shokouhinejad Single-rooted n 5 20 Mtwo rotary - 3 mL of 5.25% NaOCl - 1-mm-thick slices Gutta-percha/AH Plus, Gutta-percha/ AH Plus x Two-way ANOVA
et al., 2014 instruments - 5 mL of 17% EDTA for 1 min - 0.5 mm/min smear layer (1) EndoSequence, smear EndoSequence (1) P . .05
- Plunger with 1.82 6 0.68 layer (1) 3.55%
0.7 mm Gutta-percha/AH Plus, 1.77 6 0.69 AH Plus x
- Middle third smear layer (2) Gutta-percha/ EndoSequence (2)
1.70 6 0.67 EndoSequence, smear 9.27%
layer (2)
1.57 6 0.61

Silva et al., Maxillary incisors Artificial holes - 2.5% sodium hypochlorite - 1-mm-thick slices AH Plus 2.14 6 1.1 MTA Fillapex: AH Plus x Wilcoxon signed rank
2014 n 5 18 (NaOCl) - 0.5 mm/min 0.24 6 0.16 MTA Fillapex test with Bonferroni
- 17% EDTA - Plunger with 100% correction
- Water 0.6 mm P , .05
- 2.5% NaOCl - Middle third
- Water

Sonmez et al., Mandibular premolar Mtwo NiTi rotary - Sodium - 1-mm-thick slices AH Plus 1.27 6 0.21 MTA Fillapex AH Plus x ANOVA and Tukey
2013 n 5 30 system hypochlorite (5.25%) - 1.0 mm/min 0.46 6 0.50 MTA Fillapex P , .05
- 15% - Plunger with 1.2, ProRoot MTA 100%
ethylenediaminetetraacetic 1.0, and 0.8 mm 4.07 6 0.55 AH Plus x
acid. ProRoot MTA
- Distilled water 100%

Tedesco et al., Maxillary central ProTaper rotary - 16 mL of 1% NaOCl - 1-mm-thick slices AH Plus 7d MTA Fillapex AH Plus x ANOVA and Tukey
2014 incisors n 5 10 instruments - 3 mL of 17% EDTA - 0.5 mm/min 4.28 6 2.19 7d MTA Fillapex P , .05
- 3 mL of 1% NaOCl - 3 thirds 60d 1.30 6 0.91 7d
3.38 6 2.51 60d 97.80%
1.64 6 1.65 60d
44.91%

(continued )
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

results and interpretation are summarized in Figure 2. The

major problem of the included studies was the absence of

Two-way ANOVA and

Two-way ANOVA and

Bonferroni P , .05

Tukey test P , .05

the sample size calculation. Although only 3 studies
performed the sample size calculation,11,13,17,28 the power
ANOVA with

analysis demonstrated a satisfactory effect size for the

P , .05
Tukey
major studies.11,13,15,17,22,24,27,29,33,35,36

Summary Measures and Meta-Analysis

1% peracetic acid

After selecting the studies, it was only possible to perform the

AH Plus x iRoot

9% etidronate

MTA Fillapex

MTA Fillapex
meta-analysis with 1 brand of epoxy resin–based root canal
17% EDTA

AH Plus x

AH Plus x
sealer (AH Plus) and 2 brands of calcium silicate–based root
Cervical
57.69%

61.18%

94.32%

98.32%

99.91%

99.94%
Middle

Apical

100%
canal sealers (MTA Fillapex and EndoSequence BC Sealer
[which is also known as Total Fill BC Sealer or iRoot SP]).
Continuous variables were used and included in the software as
1% peracetic acid

means and the standard deviations. Two pair-wise pooled

9% etidronate

MTA Fillapex

MTA Fillapex
2.46 6 0.54

2.65 6 0.76

2.54 6 0.60

1.29 6 0.45

1.16 6 0.36

0.96 6 0.16

meta-analyses comparing an epoxy resin–based sealer (AH

1.54 6 1.1
17% EDTA
iRoot SP

Coronal

Plus) and a paste-to-paste calcium silicate–based root canal

Middle

Apical

sealer (MTA Fillapex) and also the AH Plus and premixed ready-
to-use calcium silicate–based root canal sealer (Endosequence
AH Plus 4.00 6 2.5
AH Plus 17% EDTA

BC Sealer) were performed. A subgroup analysis was also

1% peracetic acid

AH Plus Coronal

performed according to the root canal third used for the push-
9% etidronate
2.18 6 0.62

2.25 6 0.78

1.98 6 0.80

2.31 6 0.78

2.12 6 0.58

1.65 6 0.45

out bond strength (coronal, middle, and apical or three thirds).

Middle

Apical

Figure 3 exhibits the forest plot of the pooled comparison

between AH Plus (n 5 467) and MTA Fillapex (n 5 467),
- Plunger with 0.8,
- 1-mm-thick slices

- 1-mm-thick slices

- 1-mm-thick slices
0.6, and 0.4 mm

demonstrating higher mean push-out bond strength values

- Cervical third

(P , .001) for AH Plus with a standard mean difference and a

- 1.0 mm/min

- 0.5 mm/min

- 0.5 mm/min

confidence interval of 22.03 [22.49, 21.57], and the het-

- 3 thirds

- 3 thirds

erogeneity among the studies was 85% (I2). When the sub-
group analysis was performed according to the root
third,17,23,24,27,31 it was observed that the slices from the
- 2 mL of 5.25% sodium

- 5 mL of 2.5% NaOCl. After

CI, confidence interval; EDTA, ethylene diamine tetraacetic acid; SD, standard deviation.
saline solution, 17% EDTA
applying 10 mL of normal

coronal third presented higher mean push-out bond strength

- 10 mL of distilled water
- 5 mL of distilled water
hypochlorite (NaOCl)

- 5 mL of 2.5% NaOCl

values (P ,.001) for AH Plus, with a standard mean difference

- 5 mL of 17% EDTA.

and a confidence interval of 22.08 [22.65, 21.51], and the

heterogeneity was 7% (I2). Regarding the middle
third,11,13,17,22–24,27,28,31 the standard mean difference value
that favored the AH Plus sealer group (P , .001) was 22.34
[23.04, 21.64], and the heterogeneity was 83% (I2). The
apical third17,23,24,26,27,31 demonstrated increased values in
ProTaper rotary files

the AH Plus group (P ,.001), with a standard mean difference

ProTaper rotary

K3 NiTi rotary

and confidence interval of 22.06 [23.17, 20.96] and an I2 of

instruments

instruments

79%. Finally, when the authors assessed the push-out bond

strength of the entire root,12,27,29,33–35 the AH Plus presented
superiority in bond strength values (P 5.001) with a standard
Mandibular premolars

mean difference and confidence interval of 21.32

Single-rooted n 5 40

[22.10, 20.55] and an I2 of 87%.

Maxillary canines

The comparisons between the AH Plus (n 5 370) and

n 5 13

n 5 80

EndoSequence BC Sealer (P 5 370) are shown in Figure 4.

The pooled analysis demonstrated no significant
difference between the sealers (P , .05), with a standard
Wiesse et al.,

mean difference and confidence interval of 20.83

Yavari et al.,
Tuncel at al,

[21.62, 20.03] and an I2 of 95%. Only in the middle

2015

2017

2017

third,11,16,22,28,31 increased bond strength values were

observed for the AH Plus sealer group (P , .001), with a

- 2019 9
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 2. Quality assessment of the included studies.
standard mean difference and confidence interval of 21.54
[22.53, 2.056] and an I2 of 94%.
DISCUSSION
The meta-analysis demonstrated that AH Plus demonstrated
a higher resistance to dislodgment than MTA Fillapex (P ,
10 Volume -, Number -
.001). These results were also observed when the entire root
canal was evaluated and when the subgroup analysis was
performed according to the root third (P , .05). The higher
performance of AH Plus when compared to MTA Fillapex is
well documented in the endodontic literature.31,38–41 The
ability of AH Plus to form a covalent bond, with open
epoxide rings to exposed amino groups present in the
dentin collagen network, may explain the good resistance
to dislodgment of this sealer.42 According to the
manufacturer, MTA Fillapex is mainly composed of MTA,
salicylate resin, natural resin, bismuth oxide, and silica.
However, the percentage of each material is unknown,
except for the MTA, which is present in a relatively low
concentration (13.2%). The literature indicates that MTA
Fillapex has a high concentration of resinous
components,43,44 which raises doubts regarding the
classification of this sealer as a true calcium silicate–based
sealer. MTA Fillapex also contains pigments and bismuth
oxide, which may interfere with several properties of the
material. When the base paste mixes with the catalyst paste,
2 important chemical reactions occur: the reaction between
MTA and salicylate resin and the selective hydration of the
orthosilicate ions. However, the imbalance in the resin-MTA
reaction rate interferes with the chemical reaction between
these components and with the hydration process of MTA
Fillapex, impairing the setting and consequently affecting
critical physical properties such as solubility45,46 and resis-
tance to dislodgment,22,38,40 as shown in the present result.
Moreover, endodontic sealers based on salicylate resin
present a volumetric contraction during their setting, which
increases the contraction factor and consequently the
formation of voids at the cement-dentin interface.47
In addition, the excess fluidity and solubility of MTA
Fillapex may also increase the dimensional changes, as
well as interfere with the depth and penetration force of
this sealer in dentin tubules, anatomic irregularities, or
ramifications, producing a gap between the material and
the dentin walls. Taken together, these explanations may
support the results obtained in the present meta-analysis.
The current analysis showed no significant difference be-
tween the AH Plus and EndoSequence BC Sealer (P . .05).
In contrast to MTA Fillapex, EndoSequence BC Sealer is a
premixed ready-to-use calcium silicate–based root canal
sealer composed of zirconium oxide, calcium silicates, cal-
cium phosphate monobasic, calcium hydroxide, filler, and
thickening agents.48 This sealer has the ability to slightly
expand upon setting, and the sealer sets upon contact
with moisture naturally present in the dentinal tubules.9
Moisture is supposed to facilitate the hydration reactions,
producing calcium silicate hydrogel and calcium
hydroxide.48 The bond strength values of the
EndoSequence BC sealer may be explained by its
composition, which provides some chemical bonding

Figure 3. Forest plots of the pooled analysis and the subgroup analysis comparing AH Plus and MTA Fillapex. CI,
confidence interval; SD, standard deviation.
ability to mineralized tissues.11,15,48 Previous studies
confirmed the bioactivity of the EndoSequence BC sealer
through an x-ray powder diffraction (XRD) diffractogram
and the visualization of mineral formation on the interfacial
dentin-sealer layer.11
One important limitation of the present systematic review
was the observation of the heterogeneity in the experi-
mental protocols and reporting data, such as the method-
ology to determine push-out bond strength, evidenced by
the high Higgs index (I2 5 85%) in the meta-analysis pooled
data. For this reason, the standard mean difference was
used to perform the meta-analysis, which is more reason-
able for heterogeneous studies.49 Studies that performed
different methodological procedures to compare the
The Journal of EVIDENCE-BASED DENTAL PRACTICE
different materials were excluded. One example is the
study by DeLong et al., in which EndoSequence and AH
Plus were filled with different core materials:
EndoSequence GP cone and a conventional gutta-percha
cone, respectively.25 The studies by the authors Araujo
et al., Nagas et al., and Paula et al. were not included in
the meta-analysis because they did not provide the num-
ber of specimens per group.12,23,29 In addition, Razmi et al.
presented the shear bond strength values in Newtons30; for
this reason, it was not possible to include this study in the
meta-analysis. After eliminating the studies with missing
data or internal discrepancies that made it impossible to
obtain unbiased comparisons, meta-analysis was per-
formed. Neelakantan et al.50 previously pointed out that the
heterogeneity in methodology to determine push-out bond
- 2019 11
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 4. Forest plots of the pooled analysis and the subgroup analysis comparing AH Plus and EndoSequence. CI,
confidence interval; SD, standard deviation.
strengths prevents the comparison of these studies. How-
ever, in the present study, the meta-analysis was performed
because even though there were differences observed
related to the irrigation protocol, storage methodology,
nature of root canal filling, dentin slice thickness, and
plunger diameter, all included studies compared the sealers
under the same conditions. When different protocols were
used in the same study, an additional effort was taken to
select the most scientifically based protocol to be consid-
ered for the meta-analysis. For example, Carvalho et al.
tested different sealers under different irrigation protocols,
varying the chelating agent (17% EDTA, 2.25% peracetic
acid, or 10% citric acid). Data obtained using smear layer
removal performed with 17% EDTA were included for this
study in the meta-analysis because it is the most commonly
used protocol to remove the smear layer. Tuncel et al.14 also
evaluated the different smear layer removal protocols with
17% EDTA, 9% etidronate, or 1% peracetic acid. For the
same reasons, the shear bond strength values from the
17% EDTA smear layer removal protocol were used.
Shokouhinejad et al.16 evaluated the shear bond strength
values with and without smear layer removal, and to
12 Volume -, Number -
reduce the bias, the values from the 17% EDTA protocol
were chosen. In addition, Wiesse et al.17 evaluated the
influence of activating an endodontic sealer with sonic or
ultrasonic activation on the push-out bond strength. Data
for the sealers without any kind of activation were selected
to be included in the meta-analysis.
A total of 2292 studies were obtained from the electronic
search. However, after applying the eligibility criteria and
discarding duplicates, only 20 were included.11–14,16,17,
22–24,26–31,33–36
The risk of bias of the included studies was
evaluated using a modified quality assessment used for
in vitro studies,19,20 taking into consideration the 5 param-
eters in the implementation of the study (sample size
calculation, similar dimensions among the samples, stan-
dard preparation, standard root-filling procedures, and
adequate statistical analysis). Although this systematic re-
view was performed using in vitro models, the majority of
the studies presented a low risk of bias, demonstrating the
high quality of the included studies. For these reasons, the
results presented here provide a moderate strength of
evidence. Only the sample size calculation domain was

classified as at high risk of bias in the majority of included
studies because the sample size was not calculated.
Although the lack of sample size calculation is an important
limitation, the power of the included studies to measure the
effect size based on the push-out bond strength means,
standard deviations, and sample size for each group of teeth
was assessed. However, despite the fact that the majority of
the studies did not calculate the sample size, most of them
exhibited a satisfactory power.11,13,15,17,22,24,27,29,33,35,36 The
meta-analysis was performed using the random-effect
model because it included more than 5 studies. Owing to
the high heterogeneity among them, the standard mean
difference instead of mean difference was used. However,
the discrepancies among the study design of the pooled
meta-analysis comparing AH Plus and MTA Fillapex pre-
sented an acceptable heterogeneity of 85%. It should be
noted that the pooled meta-analysis comparing the AH Plus
and EndoSequence BC Sealer presented a high heteroge-
neity of 93%.
AH Plus (Dentsply DeTrey, Konstanz, Germany) is an epoxy
resin–based root canal sealer frequently used as a compar-
ison material in endodontics because of its properties which
include long-term dimensional stability, reduced solubility,
apical sealability, and low toxicity.51 In addition, previous
studies have pointed out that this epoxy resin–based root
canal sealer has good retention to root dentin with higher
values of push-out bond strength when compared with
other endodontic sealers.11,15,22–24,27,31 For these and other
physicochemical properties, this sealer has been considered
a “gold standard” in endodontics. Regarding the calcium
silicate–based root canal sealers, the studies are conflicting,
presenting more11,22–24 and less14,25,26 favorable results for
the push-out bond strength of this type of sealer.
Clinically, adhesion of the root filling to the dentinal walls
seems advantageous for 2 main reasons. In a static condition,
optimal adhesion leads to fewer gap-containing regions that
would allow fluid infiltration within either sealer-dentin or
sealer–core-filling material interfaces.52 In a dynamic
situation, it avoids sealer dislodgment during operative
functional procedures and consequently increases the
success rates.53 The patient-reported outcomes have
gained importance in the last few years as a relevant measure
that characterizes patients’ suffering.54 In this sense, the
impact of well-known measures such as swallow reversion,
pain resolution, success rates, and, consequently, the oral
health recovery resulting from the operative procedures can
affect the dental patients’ perceptions. The choice of an
endodontic sealer with improved mechanical properties can
improve these conventional outcomes, reducing the failures
in endodontic treatment and consequently the performance
of retreatments or extractions, providing a more rapid re-
covery of physical and emotional wellness. The patient-
perceived impact is an important and underexplored
The Journal of EVIDENCE-BASED DENTAL PRACTICE
outcome in dental interventional studies, especially in end-
odontic treatment investigations, and must be explored
more deeply in future studies.54
CONCLUSION
It can be concluded with a moderate strength of evidence
that the new bioceramic sealers do not outperform the
traditional epoxy sealers with regard to the resistance to
dislodgment.
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