Review Article

An update on bioceramic sealers

Kavalipurapu Venkata Teja, Sindhu Ramesh*

ABSTRACT

Bioceramics are widely used for repair and replacement in humans and claim to have an immense bioconductive and
bioinductive properties. These materials were developed to have biocompatibility with human tissue and be widely used
in repair and replacement. Various bioceramic-based materials have been widely used for various purposes in endodontics.
Bioactivate materials, in contrast, have osteoinductive and osteoconductive properties. They are porous and develop an
interfacial bond with the hard tissues. Hydroxyapatites, bioactive glasses, and glass ceramics are examples of this class of
bioceramics. Bioresorbable ceramics enhance the replacement resorption of the material by host tissues when the rate of
resorption correlates with the rate of regeneration. Especially in concern with root canal sealers, bioceramics are used in a
wider role of bioactivity. The present review was mainly concentrated in updating the data on bioceramic sealers.

KEY WORDS: Bioactivity, Bioceramics, Root canal sealers, Root canal treatment

INTRODUCTION Biodegradable, soluble, or resorbable – Eventually

The term “bioceramics” may be applied to the category
of biomaterials that are composed of ceramic as one
of its constituents. These materials were developed
to have biocompatibility with human tissue and be
widely used in repair and replacement of the organs in
the musculoskeletal system.[1] Sealer is a radiopaque
dental cement used, usually in combination with a
solid or semisolid core material, to fill voids and to
seal root canals during obturation.[2]
Successful outcomes of root canal treatment, in addition
to a multitude of factors, also depend on the prevention of
reinfection of the root canal space. The ultimate goal of
root canal treatment is the prevention or healing of apical
periodontitis. The use of biologically active materials to
seal root canal systems has been extensively proposed in
contemporary endodontics to realize this goal.[3,4]
BASIC CLASSIFICATION OF
BIOACTIVE MATERIALS[5,6]
Bioinert – Non-interactive with biologic systems;
Bioactive – Durable in tissues that can undergo
interfacial interactions with the surrounding tissue.
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replace or are incorporated into tissue.
Biodegradable, soluble, or resorbable – Eventually
replace or are incorporated into tissue.
Bioinert materials do not demonstrate osteoconductive or
osteoinductive properties, they allow a growth of fibrous
tissues around the material. Examples of this category are
alumina and zirconia. Bioactivate materials, in contrast, have
osteoinductive and osteoconductive properties. They are
porous and develop an interfacial bond with the hard tissues.
Hydroxyapatites (HAP), bioactive glasses, and glass ceramics
are examples of this class of bioceramics. Bioresorbable
ceramics enhance the replacement resorption of the material
by host tissues when the rate of resorption correlates with
the rate of regeneration. Examples of this group of materials
are tricalcium silicates and calcium phosphate. Bioceramic
sealers, which are the recent advancements in endodontics,
are the bioactive sealers available in the market.[7-9]
CLASSIFICATION OF
BIOACTIVE SEALERS IN
ENDODONTICS[10-14]
Broadly classified based on primary constituent as
follows:
1. Mineral trioxide aggregate (MTA)-based sealers
2. Calcium silicate-based sealers

Department of Conservative Dentistry and Endodontics, Saveetha Dental College, Saveetha Institute of Medical and
Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India

*Corresponding author: Sindhu Ramesh, Department of Conservative Dentistry and Endodontics, Saveetha Dental College,
Saveetha Institute of Medical and Technical Sciences, Saveetha University, 162, Poonamallee High Road, Chennai - 600 077,
Tamil Nadu, India. Phone: +91-98401363543. E-mail: drsinsushil@gmail.com

Received on: 19-01-2020; Revised on: 24-02-2020; Accepted on: 28-03-2020

Drug Invention Today | Vol 14 • Issue 3 • 2020 17

 Kavalipurapu Venkata Teja and Sindhu Ramesh
3. Phosphate-based bioceramic sealers
4. Calcium phosphate-based sealers.
Based on the commercial availability as
MTA-based sealers:
1. Endo-CPM-Sealers
2. MTA-Angelus
3. MTA Obtura
4. ProRoot Endo Sealer
5. MTA Fillapex.
Calcium silicate-based sealers:
1. EndoSequence BC Sealer
2. iRoot SP
3. iRoot BP.
Phosphate-based bioceramic sealers
1. Bio aggregate
Calcium phosphate-based sealers
1. Sankin apetite 1 and 2
2. Capseal 1 and 2.
Based on dispensing as:
1. Powder and liquid systems
2. Paste systems
3. Premixed syringe systems
4. EndoSequence BC sealer
5. MTA total fill.
MECHANISM OF ACTION
The calcium silicates in the powder hydrate with the
liquid to produce a calcium silicate hydrate gel and
calcium hydroxide. The calcium hydroxide reacts
with the phosphate ions to precipitate HAP and
water. The newly formed compound of HAP is a non-
toxic, bone repair, and reconstruction material. The
water continues to react with the calcium silicates
to precipitate additional gel-like calcium silicate
hydrate. The water supplied through this reaction is an
important factor in controlling the hydration rate and
the setting time as following:[15,16]
The hydration reactions (A, B) of calcium silicates can
be approximated as follows: 6 (A) 2[3CaO. SiO2] +
6H2O --->- 3CaO. 2SiO2. 3H2O+3Ca (OH)2
(B) 2[2CaO. SiO2]+4H2O --->- 3CaO. 2SiO2.
3H2O+Ca (OH)2
The precipitation reaction (C) of calcium phosphate
apatite is as follows:
( C ) 7 C a ( O H ) 2 + 3 C a ( H 2P O 4) 2 - - - > -
Ca10(PO4)6(OH)2+12H2O
Setting reaction MTA sets through an exothermic
reaction, requiring hydration of its powder to
produce the cement paste that matures over time.
18
Most important reactions are tricalcium silicate and
dicalcium silicate reacting with water to produce
calcium silicate hydrates (C-S-H) and calcium
hydroxide [Ca (OH) 2]. The bioactivity of MTA is
attributed to hydration of the powder causing Ca+2
dissolution and diffusion, reaction product formation
(CS-H and Ca[OH]2), and further reactions resulting
in apatite formation. Calcium chloride accelerates the
setting reaction, while sodium hypochlorite hinders
the formation of calcium hydroxide.
2[3CaO.SiO2] + 6H2O ---->3CaO.2SiO2.3H2O +
3Ca(OH)2
2[2CaO.SiO2] + 4H2O ---->3CaO.2SiO2.3H2O +
Ca(OH)2
7Ca(OH)2 + 3Ca(H2PO4)2 ----> Ca10(PO4)6(OH)2 +
12H2O.
The exact mechanism of bioceramic-based sealer
bonding to root dentin is unknown; however, the
following mechanisms have been suggested for
calcium silicate-based sealers:
1. Diffusion of the sealer particles into the dentinal
tubules (tubular diffusion) to produce mechanical
interlocking bonds
2. Infiltration of the sealer’s mineral content into the
intertubular dentin resulting in the establishment of
a mineral infiltration zone produced after denaturing
the collagen fibers with a strong alkaline sealer
3. Partial reaction of phosphate with calcium silicate
hydrogel and calcium hydroxide, produced through
the reaction of calcium silicates in the presence of
the dentin’s moisture, resulting in the formation
of hydroxyapatite along the mineral infiltration
zone.[17,18]
PROPERTIES OF BIOACTIVE
SEALERS
Biocompatibility
The cytotoxicity of bioceramic-based sealers has been
evaluated in vitro using mouse and human osteoblast
cells[6] and human periodontal ligament cells.[19] Most
bioceramic-based root canal sealers have subsequently
been found to be biocompatible. This biocompatibility
is attributed to the presence of calcium phosphate in
the sealer itself.
Setting Time
The ideal root canal sealer setting time should permit
adequate working time. EndoSequence BC Sealer
or iRoot SP, the setting reaction is catalyzed by the
presence of moisture in the dentinal tubules. While the
normal setting time is 4 h, in patients with particularly
dry canals, the setting time might be considerably
longer. The amount of moisture present in the dentinal
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 Kavalipurapu Venkata Teja and Sindhu Ramesh
tubules of the canal walls can be affected by absorption
with paper points, the presence of smear plugs, or
tubular sclerosis.[20]
Solubility
Both iRoot SP and MTA-Fillapex are highly soluble,
20.64% and 14.89%, respectively, which does not
meet ANSI/ADA requirements. This high solubility
is the result of hydrophilic nanosized particles being
present in both sealers which increase their surface
area and allows more liquid molecules to come into
contact with the sealer.[21]
Radiopacity
Radiopacity of EndoSequence BC Sealer to be 3.83
mm. Endo CPM sealer was found to have a radiopacity
of 6 mm due to the presence of bismuth trioxide and
barium sulfate.[22] Similarly, the presence of bismuth
trioxide in MTA-Fillapex gives it a radiopacity of
7 mm.
1. Antimicrobial properties. BC materials have a pH
of 12.7 while setting, similar to calcium hydroxide,
resulting in antibacterial effects. BC sealer was shown
to exhibit a significantly higher pH than AH Plus for a
longer duration. Alkaline pH promotes the elimination
of bacteria such as Enterococcus faecalis[21]
2. Bioactivity: Exposure of MTA and EndoSequence
Putty to phosphate-buffered saline resulted in
precipitation of apatite crystalline structures that
increased over time, suggesting that the materials
are bioactive. iRoot SP exhibited significantly lower
cytotoxicity and a higher level of cell attachment
than MTA Fillapex, a salicylate resin-based, and
MTA particle-containing root canal sealer. [22]
EndoSequence Sealer had higher pH and greater
Ca2+ release than AH Plus and was shown to release
fewer calcium ions than BioDentine (Septodont) and
White MTA.
PROS OF USING BIOACTIVE
SEALERS FOR BASED ON
IN VITRO AND CLINICAL
STUDIES[22-28]
1. Biocompatible and do it induce any critical
cytotoxic effects
2. Formation of a nanocomposite network of gel-like
calcium silicate hydrate intimately mixed with HAP,
bioceramic, and forms a hermetic seal when applied
inside the root canal
3. Precipitates calcium phosphate on hydration with
the same strength as human bone
4. iRoot BP is non-mutagenic, does not cause an
allergenic potential after multiple uses, and has a
good tolerance by subcutaneous tissue
5. High alkalinity increases its mineralization process
also its bactericidal properties (pH 12.8)
Drug Invention Today | Vol 14 • Issue 3 • 2020
6. Hydrophilic and root canal hydration aids in the
formation of calcium phosphate hence give strength
7. Low contact angle hence these features allow them
to spread easily over the dentin walls of the root
canal and to get inside and fill the lateral micro
canals
8. These new bioceramic sealers also form chemical
bonds with the canal’s dentin walls. That is why no
space is left between the sealer and dentin walls
9. They are also osseoconductive
10. Very good radiopacity (3.8 mm of Al)
11. Setting time is 3–4 h; hence, it gives ample amount
of time for placement of the root canal
12. Bioceramics do not shrink upon setting. In fact,
they actually expand slightly on completion of the
setting process
13. Furthermore (and this is very important in
endodontics), bioceramics will not result in a
significant inflammatory response if an overfill
occurs during the obturation.
ISSUES FACED ON USING
SEALERS CLINICALLY[6,29,30]
1. Changes in the environmental water content
adversely affect the setting time and microhardness
of EndoSequence BC sealer
2. Conventional retreatment techniques are not able
to fully remove bioceramic sealers.
CONCLUSION
Bioceramic-based root canal sealers show promising
results as root canal sealers. However, discrepancies
in the results of these in vitro and in vivo based
studies reveal that these sealers do not fulfill all of
the requirements demanded of the ideal root sealer.
Further studies are required to clarify the clinical
outcomes associated with the use of these sealers.
REFERENCES
1. Orstavik D. Materials used for root canal obturation: Technical,
biological and clinical testing. Endod Top 2005;12:25-38.
2. Kaur A, Shah N, Logani A, Mishra N. Biotoxicity of commonly
used root canal sealers: A meta-analysis. J Conserv Dent
2015;18:83-8.
3. Markowitz K, Moynihan M, Liu M, Kim S. Biologic properties
of eugenol and zinc oxide-eugenol. A clinically oriented review.
Oral Surg Oral Med Oral Pathol 1992;73:729-37.
4. Koch K, Brave D. A new day has dawned: The increased use of
bioceramics in endodontics. Dentaltown 2009;10:39-43.
5. Shenoy A, Shenoy N. Dental ceramics: An update. J Conserv
Dent 2010;13:195-203.
6. Nasseh A. The rise of bioceramics. Endod Prac 2009;2:17-22.
7. Jain P, Ranjan M. The rise of biocramics in endodontics: A
review. Int J Pharm Biol Sci 2015;6:416-22.
8. Best SM, Porter AE, Thian ES, Huang J. Bioceramics: Past,
present and for the future. J Eur Ceram Soc 2008;28:1319-27.
9. Hench L, Wilson J. An Introduction to Bioceramics. Singapore:
World Scientific; 1993.
10. Prati C, Gandolfi MG. Calcium silicate bioactive cements:
19
 Kavalipurapu Venkata Teja and Sindhu Ramesh
Biological perspectives and clinical applications. Dent Mater
2015;31:351-70.
11. Utneja S, Nawal RR, Talwar S, Verma M. Current perspectives
of bio-ceramic technology in endodontics: Calcium enriched
mixture cement-review of its composition, properties and
applications. Restor Dent Endod 2015;40:1-13.
12. Jitaru S, Hodisan I, Timis L, Lucian A, Bud M. The use of
bioceramics in endodontics-literature review. Clujul Med
2016;89:470-3.
13. Tanomaru-Filho M, Viapiana R, Guerreiro-Tanomaru JM. From
mta to new biomaterials based on calcium silicate. Odovtos Int
J Dent Sci 2015;17:10-4.
14. Ghoddusi J. Material Modifications and Related Materials.
Berlin, Heidelberg: Springer; 2014.
15. Zhang W, Li Z, Peng B. Assessment of a new root canal sealer’s
apical sealing ability. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2009;107:e79-82.
16. Han L, Okiji T. Uptake of calcium and silicon released from
calcium silicate-based endodontic materials into root canal
dentine. Int Endod J 2011;44:1081-7.
17. Atmeh AR, Chong EZ, Richard G, Festy F, Watson TF.
Dentin-cement interfacial interaction: Calcium silicates and
polyalkenoates. J Dent Res 2012;91:454-9.
18. Zhang H, Shen Y, Ruse ND, Haapasalo M. Antibacterial
activity of endodontic sealers by modified direct contact test
against Enterococcus faecalis. J Endod 2009;35:1051-5.
19. Kabbinale P, Chethena KC, Kuttappa MA. Role of calcium-
enriched mixture in endodontics. Arch Med Health Sci
2015;3:80.
20. Jia L, Shihai Y. Application of bioceramic material in
endodontic therapy. Chine J Conserv Dent 2012;22:241-4.
21. Bilginer S, Esener T, Söylemezoglu F, Tiftik AM. The
investigation of biocompatibility and apical microleakage
of tricalcium phosphate based root canal sealers. J Endod
1997;23:105-9.
20
22. Viapiana R, Flumignan DL, Guerreiro-Tanomaru JM,
Camilleri J, Tanomaru-Filho M. Physicochemical and
mechanical properties of zirconium oxide and niobium oxide
modified Portland cement-based experimental endodontic
sealers Int Endod J 2014;47:437-48.
23. Erdemir A, Adanir N, Belli S. In vitro evaluation of the dissolving
effect of solvents on root canal sealers. J Oral Sci 2003;45:123-6.
24. Gandolfi MG, Prati C. MTA and F-doped MTA cements used
as sealers with warm gutta-percha. Long-term study of sealing
ability. Int Endod J 2010;43:889-901.
25. Morgental RD, Vier-Pelisser FV, Oliveira SD, Antunes FC,
Cogo DM, Kopper PM. Antibacterial activity of two MTA-
based root canal sealers. Int Endod J 2011;44:1128-33.
26. Tanomaru-Filho M, Silveira GF, Tanomaru JM, Bier CA.
Evaluation of the thermoplasticity of different gutta-percha
cones and Resilon. Aust Endod J 2007;33:23-6.
27. Costa BC, Guerreiro-Tanomaru JM, Bosso-Martelo R,
Rodrigues EM, Bonetti-Filho I, Tanomaru-Filho M. Ytterbium
oxide as radiopacifier of calcium silicate-based cements.
physicochemical and biological properties. Braz Dent J
2018;29:452-8.
28. Prullage RK, Urban K, Schafer E, Dammaschke T. Material
properties of a tricalcium silicate-containing, a mineral trioxide
aggregate-containing, and an epoxy resin-based root canal
sealer. J Endod 2016;42:1784-8.
29. Tanomaru-Filho M, Garcia AC, Bosso-Martelo R, Berbert FL,
Reis JM, Guerreiro-Tanomaru JM. Influence of addition of
calcium oxide on physicochemical properties of Portland cement
with zirconium or niobium oxide. J Conserv Dent 2015;18:105-8.
30. Mohammadi Z, Giardino L, Palazzi F, Shalavi S. Antibacterial
activity of a new mineral trioxide aggregate-based root canal
sealer. Int Dent J 2012;62:70-3.
Source of support: Nil; Conflicts of interest: None Declared
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