Comparison of the sealing ability of the CC sealer and Endoseal MTA sealer by the dye penetration method: A lab-based experimental study

doi:10.21203/rs.3.rs-5268648/v1

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Comparison of the sealing ability of the CC sealer and Endoseal MTA sealer by the dye penetration method: A lab-based experimental study

https://doi.org/10.21203/rs.3.rs-5268648/v1

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Background and Aim: In addition to gutta-percha, different bioceramic materials, such as cold ceramics and MTA, are also used as root-filling materials. Owing to the good sealing properties of bioceramics, in this study, we compared the sealing ability of the CC sealer and Endoseal MTA sealer by the dye penetration method.

Materials and Methods: In this laboratory study, 32 human single-root teeth were used. After canal preparation, the teeth were randomly divided into two equal groups of 13 teeth according to the root canal fillings, which were filled with CC Sealer and Endoseal MTA Sealer via the lateral condensation method. After that, the teeth were stored at 100% humidity and a temperature of 37°C for 10 days. The samples were then stored in normal saline for one month. All the teeth were subsequently dried, and the dental surfaces, with the exception of the apical foramen, were covered with two layers of nail polish. All the samples were immersed in a 2% methylene blue solution for 72 hours. After the teeth were cut longitudinally, the pieces were examined via 20x magnification microscopy.

Results: According to the results of the Mann‒Whitney U test, although the average amount of dye penetration in the CC sealer group, with a value of 1/40 ± 0/64 mm, was less than the average amount of dye penetration in the Endoseal MTA group, with a value of 2/12 ± 1/74 mm, this difference was not statistically significant (P value = 0.418).

Conclusion: Considering the results of the present study and the limitations of laboratory studies, CC sealer and Endoseal MTA sealer seem to have similar sealing abilities. However, the distribution of dye penetration in the Endoseal MTA group was greater than that in the cc sealer group. This can mean that the results are more uniform when the canals are filled with a CC sealer.

Additionally, during the study, CC Sealer presented a longer setting time, which allows it to work better with.

Root canal therapy

Root canal filling materials

Cold ceramic

MTA

Pulp and periapical diseases are caused by the exposure of these tissues to bacterial infectious agents (1). The success rate of endodontic treatment generally depends on three main steps: 1- removal of infected pulp from the tooth, 2- cleaning and shaping of the root canal, and 3- filling the root canal with inert substances. Although each stage has its own importance, the success of treatment is fundamentally dependent on the last stage(2).

Therefore, the ultimate goal of endodontic treatment is to create a complete seal along the entire length of the canal from the coronal foramen to the apical foramen (1).

Different materials are used for root filling, such as gutta-percha, silver cones, calcium hydroxide, glass ionomers, and ZOE(3). The most common material used for root canal filling is gutta-percha with endodontic sealers(4). Sealing is essential for increasing the sealing ability of gutta-percha(5). The sealers act as lubricants for easier insertion of filling materials, and they also fill lateral canals along the root (6).

An ideal root filling material should seal all pathways between the root canal system and periapical and periradicular tissues. It must also be nontoxic, noncarcinogenic, biocompatible, insoluble in tissue fluids, and dimensionally stable. In addition, the presence of moisture should not affect its sealing ability. It should be easy to use and opaque for radiographic diagnosis(1). Studies have shown that none of the recent sealers have all of these ideal features, but some have more suitable features than others do(7).

Among the different types of endodontic sealers, bioceramic sealers (based on calcium silicate) have become popular in recent years because of their characteristics, such as dentin remineralization, acceptable cytotoxicity, antibacterial effects, and penetration into dentin tubules.(8, 9) Additionally, bioceramic sealers do not shrink during setting, increasing their sealing ability.(10) In addition, these types of sealers have the ability to adapt to canals, which reduces microleakage(11, 12). These sealers are hydrophilic, and the hydroxyapatite contents are bonded with the dentin wall. During setting, their pH reaches 12, which results in very high antibacterial activity(13). Bioceramics have been successfully used in root canal treatments, pulp capping, canal filling, apical plugging and perforation repair(14). Pro-root MTA, Biodentine, Retro MTA, Ortho MTA and cold ceramic are examples of bioceramic sealers used in dentistry.

The first bioceramic material that was successfully used in endodontic treatment was MTA, which was introduced by Dr. Torabi Nejad in 1993(15).

MTA has been found to have anti-inflammatory effects on pulp tissue, and its osteoconductive and cementoconductive effects have been confirmed. Despite its many advantages, a long setting time, difficult handling, and difficulty of removal after insertion are the main disadvantages of MTA (16).

One of the bioceramic sealers is the Endoseal MTA sealer, which is made in South Korea(17). Endoseal MTA is based on MTA pozzolan cement(18). It is composed of calcium silicates, calcium aluminates, calcium aluminifera, and calcium sulfates. (19). This sealer can be injected(17) and set by absorbing moisture from the environment(19). Endoseal MTA has good biocompatibility, and its manufacturers claim that, in addition to its high seal potential, it is easy to use clinically.(17)

On the other hand, Endoseal MTA has disadvantages such as color change, long setting time, low working time (less than 4 minutes), insufficient compressive strength and a lack of known solvents(19), but it is commonly used.

Cold ceramics were first introduced in 2000(20). X-ray fluorescence revealed that four compounds, calcium oxide, silicon oxide, barium oxide and sulfur oxide, make up 93% of the chemical composition of this substance(20).

This material has desirable properties for use in one-session apexification. The initial setting of this material is achieved in the presence of moisture for approximately 10–15 minutes, and the material becomes completely set within 24 hours(21). The sealing ability of this material has been reported to be greater than that of glass ionomers and amalgams(22–24). Additionally, electron scanning microscopy (SEM) revealed that CC and ProRoot MTA are similar in terms of marginal adaptation(25)

The CC sealer is based on a cold ceramic; a single cone can also be filled. It is offered in powder and liquid form, and the ratio of powder to liquid is 2:1. The setting time outside the oral environment may be up to a few days, but in teeth, it is approximately 6 hours because it absorbs moisture from dentin. The sealer is initially soluble in water before setting. Therefore, if the canal has exudate, it may be washed out, and the clinician should pay attention to it.

The present lab-based experimental study was conducted in 2024 at Shahid Sadoughi Dental University of Yazd with the aim of comparing the sealing ability of the Endoseal MTA sealer and CC sealer via the dye penetration method.

In this study, 13 human single-root teeth were used (Ethics code: IR.SSU.REC.1402. 016), the number of samples was selected on the basis of previous studies(26)

The inclusion criteria were single canal extracted teeth, human extracted teeth, roots without fracture and severe damage, and fully formed apex teeth, and the exclusion criteria were root fractures, teeth with developmental anatomy and an open apex.

After suitable teeth were selected to disinfect the samples, all the teeth were immersed in 5.25% sodium hypochlorite (Nikdarman-Iran)for 30 minutes.

After the access cavity was prepared, the length of the canal was determined by inserting a K file (Mani-Japan) No. 15 into the canal of each tooth. The working length was determined by reducing the length by 1 mm.

Two-thirds of the crown and middle of the canals were prepared successively via Gates Glidden Nos. 2, 3 and 4 (Mani-Japan), and one-third of the canals were prepared apically via manual files via the stepback method (Final File No 45). Chemical cleaning of canals was performed by using 5.25% sodium hypochlorite between each file. After that, we used 1 mL of 17% EDTA (Aria dent-Iran) for 60 s to remove the smear layer. The final cleaning was performed with 1 ml of normal saline. The canals were subsequently dried with sterile paper points.

The teeth were randomly divided into two equal groups of 13 according to the root canal filling materials:

Group 1: CC sealer (Yazd-Iran) + gutta-percha (Diadent-Korea) via the lateral condensation method

Group 2: Endoseal MTA sealer (Maruchi: Wonju, Korea) + gutta-percha by lateral condensation.

To test the sealing ability of nail polish and dye penetration, 3 roots without sealer were filled with gutta-percha via the lateral condensation method and were considered a positive control group.

In addition, 3 roots were considered the negative control group. They were filled with gutta-percha and Endoseal MTA

The CC sealer was applied via a low-speed spiral lentulo (Endoperfection-German), and in the Endoseal MTA group, the sealer was injected into the canals.

After that, a cavit dressing was placed in the access cavity of each tooth. The teeth were stored at 100% humidity and a temperature of 37°C for 10 days to set the material. The samples were then placed in normal saline for one month to release the hydrophilic solvent.

All the teeth were subsequently dried, and the dental surfaces, with the exception of the apical foramen, were covered with two layers of nail polish.

The negative control group was completely covered with two layers of nail polish (even the apical foramen).

All the samples were immersed in a 2% methylene blue solution for 72 hours.

The teeth were subsequently cut longitudinally in the buccolingual direction via a diamond fissure bur (Diadent-China).

After that, the tooth sections were evaluated to examine the penetration of dye in the apical part via a light microscope (Zeiss-Germany). The amount of dye penetration in each sample was measured in millimeters. They were measured by a person who was not aware of the experimental groups.

In this experimental-laboratory study, with the aim of comparing the sealing ability of the Endoseal MTA sealer and CC sealer via the dye penetration method, 26 human single-canal teeth were selected for study and were randomly divided into two experimental groups: the gutta-percha-Endoseal MTA sealer (13 samples) and the gutta-percha-cc sealer (13 samples).

In the positive control group (3 samples), the color had completely penetrated, and in the negative control group (3 samples), no color penetration was observed in the canals, which indicates the accuracy of the study method.

To analyze the data, first, the normality of the color penetration rate was investigated via the Shapiro‒Wilk test. Because the data were not normally distributed (P value < 0/05), the nonparametric Mann‒Whitney U test was used to analyze the data.

According to the results of the Mann‒Whitney U test, although the average amount of dye penetration in the gutta‒percha‒cc sealer group, with a value of 1/40 ± 0/64 mm, was less than the median amount of dye penetration in the gutta‒percha‒Endoseal MTA sealer group, with a value of 2/12 ± 1/74 mm, this difference was not statistically significant (P value = 0.418). Additionally, the distribution in the Endoseal MTA group was greater than that in the CCSealer group. This can mean that the result of filling with Endoseal MTA is not uniform, and in some cases, it works better, whereas in others, it is worse (Table 1 and Fig. 5). Additionally, during the study, CC Sealer presented a longer setting time, which allows it to work better.

Table 1

Determination and comparison of gutta-percha-endoseal MTA and CC sealer dye penetration
Group	Number of samples	Mean± Standard deviation	Median (1st and 3rd quartile)	Minimum	Maximum	P Value	Effect size**
Gutta percha-cc sealer	13	0/64 ± 1/40	1/25(1, 2)	0	6	0/418	0.326
Gutta percha- Endoseal MTA	13	1/74 ± 2/12	1/5(1,3/5)	0	2	0/418	0.326

* Mann‒Whitney U test **Cohen’s d

Stability to prevent the penetration of irritants is a prerequisite for the success of endodontic treatment. (27).

Therefore, filling a clean and shaped root canal is an important step in endodontic treatment to prevent bacteria and their byproducts from penetrating into the root canal and to prevent recolonization of residual bacteria after root canal treatment(28).

The most common and well-known root canal filling material is gutta-percha(29). However, it cannot be used to fill the canal on its own because it does not have enough adhesion. Although heat or some kind of solvent can be used to better seal the gutta-percha, a sealer or cement is needed to obtain the final seal(30).

However, there is still a large gap between the dentin surface and the filling material, which can lead to leakage(31). Therefore, it is necessary to study new materials because of the good sealing properties of bioceramics(32). In this study, the sealing ability of CC Sealer and Endoseal MTA was investigated.

In studies, various methods are used to evaluate apical microleakage, such as dye penetration, radioisotope, bacterial penetration, electrical impedance or resistance, distance measurement with electron microscopy, or liquid filtration. Each technique has significant limitations that can lead to errors(33).

Although the dye penetration method has several disadvantages, such as checking for microleakage in only two dimensions, semiquantitative information, loss of sample during the test, and impossibility of retesting, owing to its simplicity, low cost and convenience, it is one of the most popular and common techniques for investigating microleakage (34). As a result, this method was used in the present study.

In 2019, Moazami et al. compared the filling quality using the Endoseal MTA sealer in the single cone method and lateral condensation and reported that this sealer had significantly fewer bubbles in the lateral condensation method(19). In the present study, canal filling was performed via lateral condensation.

There are different sealers that are known as bioceramics, but in fact, they are not bioceramics and have different characteristics. Bioceramics have been added as fillers

Studies on bioceramic sealers have usually revealed better seals than sealers based on resin and ZOE:

In a 2017 study, Ballullaya et al. measured dye penetration of 6 different types of sealers: zinc oxide eugenol-based sealer, seal apex, AH plus, MTA plus, Endo Rez, and Endo sequence BC. The results of this study revealed that sealers with bioceramic bases had the lowest amount of dye penetration and that sealers with ZOE-based materials had the highest amount of dye penetration(35).

In 2021, Patri and colleagues conducted a study on the marginal adaptation of resin-based and bioceramic sealers via electron microscopy. The results of this study showed that bioceramic sealers had significantly better seal ability and marginal adaptation than other sealers(36).

In a study by Padmawer et al., who evaluated the marginal adaptations of Endosequence BC RCS sealers AH26 and EndoRez via electron microscopy, the shortest distance was significantly associated with bioceramic sealers(37).

The CC sealer is a new sealer, so our study is very important. Various studies have investigated the antimicrobial and microleakage properties of this sealer, which can be described as follows:

In 2023, the results of Hasanzadeh Salmasi’s study revealed that there was no significant difference in reducing the number of colonies of Enterococcus faecalis in dentin tubules after treatment with CC Sealer or Endoseal MTA after 30 days, and both had the same antimicrobial properties against this bacterium(38). In our study, the sealing abilities of these two sealers were similar.

In 2023, Bagheri Hariri's study, which was conducted via electron microscopy, revealed that the marginal adaptation of canals filled with gutta-percha-CC Sealer was better than that of canals filled with gutta-percha-AH26 (39). Additionally, Rafiei's study revealed that, on the basis of dye penetration, the amount of microleakage of the gutta-percha-CC sealer was significantly lower than that of the gutta-parcha-AH26 (40).

As mentioned, the Endoseal MTA sealer and CC sealer are based on MTA and cold ceramics, respectively. There are various studies on MTA and cold ceramics, the results of which can be generalized to these two sealers as well:

In 2003, Tabrizi Zadeh and colleagues compared the microleakage of amalgam, MTA and cold ceramic by the dye penetration method. The results of this study indicated that the amount of microleakage in cold ceramics was significantly lower than that in the other two groups(24). However, in the present study, the sealing abilities of the CC sealer (based on a cold ceramic) and Endoseal MTA were similar.

In 2015, Mokhtari et al. conducted a comparative study of the marginal adaptations of cold ceramics and MTAs. The marginal adaptations of these two materials were not significantly different (41). In our study, the amount of dye penetration in CC sealer (based on cold ceramics) and Endoseal MTA was not statistically significant.

In the study of Hasheminia et al. in 2013, the seal properties of MTA and cold ceramics in different environments were compared. The lowest linear leakage was observed in the cold ceramic group in the blood-contaminated environment, and the highest linear leakage was observed in the MTA group in the blood-contaminated environment(33). This finding indicates that cold ceramics are less sensitive to blood, which is probably true for CC sealers.

A 2023 study by Modresi et al., conducted via electron microscopy, revealed that the marginal adaptation of cold ceramics is better than that of the gutta-percha-Endoseal MTA (42).

In the present study, although the dye penetration of CC sealer (based on a cold ceramic) and Endoseal MTA was not statistically significant, it was numerically lower in CC sealer. Additionally, the distribution of dye penetration in the CC Sealer group was less than that in the Endoseal MTA group. This means that we have more consistent results in filling canals with the CC sealer, and the clinician can use this sealer more confidently.

The study of Mokhtari et al. in 2024 revealed that the average leakage of cold ceramic and MTA was equal during 3 days of storage in methylene blue, and after 6 months, the cold ceramic had a slightly lower amount of leakage, but the leakage of MTA was not different. (43). This study revealed that over time and in a humid environment, some reactions create a better seal for cold ceramics. In our study, the distribution of dye penetration in the gutta-percha-Endoseal MTA group was greater than that in the CC sealer group. The results of the current study may differ in the long term.

In the case of bioceramic sealers, the biological activity of a material depends on its ability to hydrolyze and produce calcium hydroxide, which helps to form a layer of hydroxyapatite between the root filling material and the dentin surface. The formation of this substance between dentin and filling materials increases with the activity of pyrophosphatase, which is also enhanced by the formation of calcium ions(44).

The results of Khedmat et al.'s study revealed that both cold ceramics and MTA can increase the enzymatic activity of alkaline phosphatase. This enzyme typically plays an important role in the initial formation of mineral tissue and the induction of hydroxyapatite deposition(45). To confirm this point, we used MTA to fill the root canal and observed that a layer of hydroxyapatite crystal was deposited between the MTA and the dentin wall, which can increase the sealing ability(46). Farahnak noted that the reason for the greater compatibility of cold ceramics with dentin walls is the release of calcium from cold ceramics and its reaction with the phosphorus in the tooth structure and the formation of hydroxyapatite crystals, which can partially fill the microscopic space between the wall and material(47).

Another mechanism of bonding a bioceramic-based sealer to dentin is the release of sealer particles into the dentin tubule to form a biomechanical bond. Owing to their alkaline pH, these sealers have the ability to denature collagen and penetrate into intertubular dentin(48)

Further studies are needed to prove these possible causes. Complex clinical conditions, including host defense and reactions that occur after canal filling in tooth tissue, may make it impossible to generalize the results to in vitro studies.

On the basis of the results of the present study and considering the limitations of laboratory studies, CC sealer and Endoseal MTA sealer seem to have similar sealing abilities. However, the distribution of dye penetration in the Endoseal MTA group was greater than that in the CC Sealer group. This can mean that the results are more uniform when canals are filled with a CC sealer. Additionally, during the study, CC Sealer presented a longer setting time, which allows it to work better.

Ethics approval and consent to participate:

Ethics code: IR.SSU.REC.1402. 016

Consent for publication:

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No funding

Authors’ contributions

JM, NF and MS are conceived and designed the study and completed the first draft. JM & NF developed the search strategy, JM and MS completed the database searches JM, NF and MSH provide feedback on early drafts. All authors made final decisions about article verification with consensus from all authors. JM, MSH provided guidance and editorial support and all authors read and approved the final

Acknowledgement

The authors would like to thank Department of Endodontics, School of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

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No competing interests reported.

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Supplementary Files

Status:

Version 1