Use Of Bioceramic Cements In Endodontics: Characteristics And Benefits

ABSTRACT

Bioceramic materials have been used with versatility in dentistry. They can serve as repair materials, being used as root repairs and for perforations, as well as obturation materials. They offer various advantages, such as biocompatibility, dimensional stability, antimicrobial and antifungal activity, increased root resistance, low cellular toxicity, and chemical stability. However, solubility is a disadvantage, noted in several studies as a negative aspect. Their composition includes calcium hydroxide, tricalcium and dicalcium silicates, calcium phosphates, and zirconium oxide as a radiopacifier. Therefore, it is observed that bioceramic cements have promising characteristics for use in endodontic treatment.

Keywords: endodontics; calcium silicate; root canal therapy.

1. INTRODUCTION

The field of Endodontics is constantly evolving, driven by the introduction of new techniques and technological advances. A fundamental part of this progress is the continuous improvement of the materials used. Bioceramics emerge as a recent innovation that has significantly impacted the transformation of this field (Raghavendra et al., 2017).

These biocompatible ceramic materials exhibit remarkable properties, including excellent sealing ability, antibacterial and antifungal activity. Their composition, which incorporates tricalcium and dicalcium silicates, calcium phosphates, calcium hydroxide, and zirconium oxide as a radiopacifier, contributes to their efficacy (Jitaru et al., 2016).

Bioceramic cements are standing out in endodontics as a versatile option, being used for perforation repair and as root canal filling material. Their characteristics, such as biocompatibility, high pH, non-resorption, ease of handling, and chemical stability, have been valued by professionals (Najafzadeh, Fazlyab e Esnaashari, 2022).

Although there is debate in the literature regarding the biocompatibility of tricalcium silicate-based cements compared to resin-based ones, they are considered a promising new generation of endodontic cements. Their properties, such as reduced particle size, non-toxicity, tissue compatibility, and high hydrophilicity, make them attractive to dental specialists(Sheela et al., 2023).

The application of these cements has proven efficient in eliminating long-term microleakage, providing adequate sealing between gutta-percha and the root canal walls. These materials not only fill gaps but also establish a chemical bond with the dentinal walls, contributing to dimensional stability after setting (Shaik et al., 2021).

It is important to emphasize that the use of a biocompatible endodontic cement is essential for adequate root canal obturation, ensuring direct contact with the periapical tissue without causing adverse reactions. The chosen materials must not only be biocompatible, but also exhibit physical properties that ensure effective and durable sealing (Sheela et al., 2023).

2. OBJECTIVE

   
   

This study aimed, through a literature review, to analyze the characteristics and benefits of bioceramic materials in endodontics.

3. LITERATURE REVIEW

Jitaru et al. (2016), in a literature review study, addressed the main materials used in endodontics and their specific characteristics. The research analyzed articles from the last 10 years and highlighted that conventional endodontic cements, which traditionally incorporate substances such as zinc oxide, calcium hydroxide, and resin, have a solid history of scientific investigation and practical application in endodontics. However, for specific cases such as perforations, apexification, root resorptions, and retrograde fillings, new materials with greater biocompatibility emerged, including ProRoot MTA, Biodentine, Endosequence BC Sealer, Bioaggregate, and Generex A, aiming to improve clinical outcomes. In summary, they noted that, despite the limited availability of bioceramic products in the market for endodontics, the scientific evidence tends to favor these materials in terms of efficacy. Therefore, the authors highlighted that as more products are introduced to the market and more research is conducted, even more solid data regarding clinical outcomes will be provided.

Al-Haddad and Aziz (2016), conducted an extensive review of the endodontic literature on bioceramic-based endodontic cements. The authors evaluated clinical and laboratory results regarding both chemical and physical properties of calcium silicate-based cements, associated with comparative studies with other types of cement. The review was subdivided into topics covering different sealer properties: biocompatibility, sealing ability, adhesion, solubility, and antibacterial efficacy. They concluded that bioceramic-based root canal cements are showing promising results, but inconsistencies remain in the studies, indicating that these materials do not completely meet the ideal requirements for root canal cements. However, due to their biocompatibility and ability to promote mineral tissue formation, these cements may find alternative applications, such as direct pulp capping and root canal filling during obturation. Therefore, they suggested that more research is needed to clarify clinical outcomes related to the use of this cement.

Raghavendra et al. (2017), presented a literature review on bioceramics in endodontics. In this study, they described an overview of the classification and advantages of this material, as well as detailed notes on bioceramic materials used in endodontics, including their applications and properties, such as biocompatibility, antibacterial activity, setting time, and sealing ability. Among the materials analyzed were MTA, EndoSequence, Generex A, Biodentine, BioAggregate, and Endobinder. Therefore, the authors concluded that although MTA had been considered a standard in calcium silicate-based materials, advances in the field have continuously sought to overcome its limitations and improve its characteristics, given that these materials cover an extensive range of uses, both in endodontics and restorative dentistry. Thus, they proposed that staying informed about these new bioactive materials is essential for ensuring the selection of the most appropriate material for the various clinical situations.

Wang, Liu and Dong (2018), conducted an in vitro study on the quality of bioceramic cement in filling and penetration of dentinal tubules. In the root selection process, 42 roots from extracted adult lower incisors were chosen and subsequently instrumented with the Protaper Universal manual file system up to the F3 file. After the instrumentation phase, 40 roots were selected and randomly divided into 4 groups: group with single-cone obturation technique and AH Plus cement, group with single-cone obturation technique and IRoot cement, group with vertical condensation technique and AH Plus cement, and group with vertical condensation technique and IRoot cement. Each sample was subsequently divided at three specific points, located 2, 4, and 6 mm from the apical end. From these divisions, the percentages of unfilled areas, gap areas, and cement segments that penetrated the dentinal tubules were determined. Statistical analysis was conducted using a non-parametric test, with a significance level of α =0.05. The results revealed that the different filling techniques and sealer types did not exert a significant influence on the presence of unfilled areas or gaps. However, they observed that iRoot SP segments showed statistically greater penetration into the dentinal tubules compared to AH Plus, especially when using single-cone and warm vertical techniques at 2 mm from the apical end (P<0.05). Finally, they concluded that regardless of the filling technique adopted, iRoot SP demonstrated comparable filling ability and greater penetration capacity into the dentinal tubules compared to AH Plus. However, they noted that this conclusion requires further investigation.

Al-Saudita et al. (2019), presented a study aimed at histopathologically analyzing pulp healing after direct pulp capping with TotalFill and Neo MTA Plus calcium silicate-based materials in extracted human teeth. In the study, forty sound premolars, recently extracted for orthodontic reasons, were randomly divided into two groups: Group I: TotalFill and Group II: Neo MTA Plus. In both groups, the teeth were prepared with Class V cavities, then the pulp exposure was sealed with one of the test materials and subsequently restored with glass ionomer cement. Furthermore, after periods of three weeks and three months, the teeth underwent demineralization, sectioning, and staining for histopathological evaluation. All data were collected and statistically analyzed using Fisher's test, with the significance level set at P-0.05. Finally, the authors concluded that TotalFill and Neo MTA Plus showed similar results in terms of favorable pulp healing and repair, with TotalFill being capable of forming a thicker dentinal bridge than Neo MTA Plus.

Candeiro et al. (2019), conducted a study aiming to evaluate the penetration capacity into artificial lateral canals of two endodontic cements: bioceramic Endosequence BC and AH Plus epoxy resin-based. The authors collected twenty-six upper first premolars with two roots, which were instrumented using K3 files up to size 40.06. Lateral canals were prepared in two diameters (0.06 and 0.10 mm), in each root, totaling six canals, with a working length of 2, 4, and 6 mm. The dental elements were randomly distributed into two groups, based on the endodontic cement to be used, and subsequently obturated using the single-cone technique. The samples were photographed using digital periapical radiography, and scores from 0 to 4 were assigned based on the degree of cement penetration into the lateral canals. Data were statistically analyzed using the Kruskal-Wallis and Student-Newman-Keuls tests, with a significance level set at p < 0.05. No significant difference was observed between the two endodontic cements used for filling the simulated lateral canals (p > 0.05). The diameter of the lateral canals only influenced the ability of Endosequence BC Sealer to fill the canals, with greater penetration in the 0.10 mm diameter lateral canals (p < 0.05). Therefore, the authors concluded that the calcium silicate-based endodontic cement Endosequence BC Sealer demonstrated similar capacity to AH Plus in filling simulated lateral canals.

Von Arx et al. (2020), presented a study that detailed the analysis of one-year follow-up results of 150 patients, with 174 treated teeth submitted to apical surgery using a new bioceramic root repair material (BCRRM). During the procedure, modern techniques were used, including the use of a surgical microscope and ultrasonic root cavity preparation. After one year, 170 teeth could be re-examined, with a dropout rate of only 2.3%. Treatment outcomes were evaluated clinically and radiographically, with an overall success rate of 94.1%, an uncertainty rate of 4.1%, and a failure rate of 1.8%. Although the lowest success rate was observed in lower premolars (86.7%), this difference was not statistically significant. In conclusion, the authors noted that BCRRM proved to be a biocompatible filling material with excellent outcomes after one year, comparable to recent studies in apical surgery, highlighting its efficacy and safety.

Almohaimede et al. (2020), conducted an in vitro study to evaluate the fracture resistance of roots filled with bioceramic (TotalFill) and epoxy resin-based (AH Plus) sealers. Fifty-nine lower premolars with single roots were selected and maintained in 0.1% thymol solution until the start of the experiment. For the study, exclusion criteria were determined: presence of calcifications, fractures, incompletely formed apices or larger than a #25 K-type file, previous endodontic treatment, pronounced curvature, dilacerated root, internal or external root resorption, and caries. In addition, radiographs were taken in buccolingual and mesiodistal directions to confirm the existence of a single canal. The selected dental elements were randomly divided into four groups: group I (n=14), canals were not instrumented or obturated; group II (n=15), canals were instrumented but not obturated; groups III and IV (n=15 each), canals were instrumented and obturated with gutta-percha/TotalFill and gutta-percha/AH Plus, respectively. The fracture resistance of the roots was evaluated using a universal testing machine, recording the maximum force in Newtons (N) required to fracture each root. Data were analyzed using the Kruskal-Wallis test, followed by the Dunn-Bonferroni post hoc test. The significance level was set at 0.05 (P≤0.05). The TotalFill group demonstrated slightly higher resistance (734.62 N) compared to the AH Plus group (728.29 N), however this difference was not statistically significant (P>0.05). The highest mean fracture force was evidenced in the negative control group (913.915 N), with a statistically significant difference compared to the other groups (P<0.05). In summary, the authors concluded that, within the limitations of the study, both endodontic treatments performed with gutta-percha/TotalFill and gutta-percha/AH Plus did not reinforce teeth against root fracture.

Retana-Lobo et al. (2021), evaluated the bond strength of premixed and powder-liquid calcium silicate-based sealers with or without gutta-percha cone. Root dentine samples from 80 single-rooted human teeth were collected. After root canal preparation with the ProTaper system and irrigation with specific solutions, the teeth were divided into four groups, each receiving a different type of endodontic cement: AH Plus, EndoSequence BC Sealer, ProRoot Endo Sealer, and BioRoot. Each group was then randomly subdivided into two subgroups for different obturation methods. After an incubation period of thirty days, maintained at 37°C and 100% humidity in calcium-free PBS, the push-out bond strength was measured, and the teeth were examined to identify the type of failure. The pH and calcium ion release were monitored over time, and additional analyses were performed to characterize the endodontic cements. The results showed that bond strength was influenced by the obturation method and the type of cement used. Notably, BioRoot showed superior bond strength compared to EndoSequence® BC Sealer. Adhesive failures predominated in teeth obturated with the single-cone technique, while cohesive failures were more common in those obturated with cement only. Furthermore, powder-liquid bioceramic cements demonstrated greater alkalinization capacity and calcium ion release compared to the premixed sealer.

Palczewska-Komsa, Kaczor-Wiankowska and Nowicka (2021), conducted a systematic review on MTA HP material covering its specific characteristics. According to the authors, MTA HP exhibited several physical-chemical and biological characteristics that make it a promising option in endodontic procedures. Regarding physicochemical properties, studies demonstrated that the setting time of MTA HP is longer compared to MTA Angelus, due to the presence of calcium tungstate in its composition, which also contributes to improved physicochemical, antibacterial, and biological properties. Furthermore, the presence of a plasticizer in the MTA HP formulation further reduces the setting time, providing practicality during the procedure.

Regarding flow and dimensional change, MTA HP met adequate standards after ultrasound activation, while studies highlighted its low solubility and water sorption, essential for ensuring material stability. In terms of film thickness, bonding, and compressive strength, MTA HP showed smaller film thickness compared to MTA Angelus, although its compressive strength increases over time, making it more durable under occlusal stress. Regarding marginal adaptation and microleakage, it was found that the acoustic force of ultrasound improves MTA HP's adaptation to root canal walls, while its color stability and resistance to discoloration highlighted it as a superior option to conventional MTA. Regarding biological properties, studies showed that MTA HP can trigger an initial local inflammatory reaction, but this response diminishes over time, and its cytotoxicity is low, with high cell viability. Furthermore, MTA HP demonstrated superior mineralization capacity and antibacterial effect against some bacterial strains, although it is not effective against anaerobic bacteria. Finally, they emphasized that these characteristics make MTA HP a valuable option in endodontic procedures, although more in vivo studies are needed to confirm its efficacy in clinical environments.

Toubes et al. (2021), presented case reports addressing the management of lateral perforation using Bio-C Repair, in the middle cervical third of the root in two upper incisors with canal calcification. They performed digital radiographic examinations at different angles and requested cone beam computed tomography (CBCT) images to provide precise visualization of canal position, perforation location, and guidance for treatment planning. After the cavitary access stage, the perforation was identified, granulation tissue was removed, and the main canal was subsequently lined with calcium hydroxide. At the second appointment, the perforation was filled with Bio-C Repair, the canals were obturated, and the dental elements were restored with a fiber glass post, 4 mm beyond the perforation level, and temporary crowns were placed. After a period of 1 year, clinical and radiographic evaluation was performed, confirming the functionality and absence of painful symptomatology in the treated teeth. In summary, the authors concluded that the bioceramic Bio-C Repair expedited the treatment of endodontic complications in its ready-to-use presentation, resulting in time savings. However, long-term observational studies were recommended to reinforce evidence on the efficacy of this repair cement.

Angkasuvan et al. (2021), presented a study with canals obturated with calcium silicate-based cement compared to canals medicated with calcium hydroxide in order to evaluate pH and calcium ion release on the external dentin surface of simulated external root resorption cavities. Sixty extracted human teeth were selected and instrumented, and external root resorption cavities were subsequently prepared on the lingual surface of the root. The dental elements were randomly distributed into three groups: Group 1 (bioceramic cement) - canals were obturated with gutta-percha and BioRoot cement; Group 2 (calcium hydroxide) - canals were medicated with UltraCal XS; and Group 3 (control) - canals were left empty. After division, thirty samples were used to evaluate pH at 7, 14, and 28 days (n=10 per group), and another thirty were used to evaluate calcium ion diffusion at 28 days (n=10 per group). The calcium hydroxide-treated group recorded the highest pH values at all time intervals (7, 14, and 28 days). Both the calcium hydroxide group and the calcium silicate-based sealer group showed significantly higher mean pH values compared to the control group (p < 0.001). Furthermore, within each group, there was a significant decrease in mean pH values over time for the bioceramic sealer and calcium hydroxide, while the control group showed no significant differences between days 7, 14, and

28. Both the calcium hydroxide and the calcium silicate-based sealer-treated groups demonstrated significantly greater calcium ion release compared to the control group. Notably, the bioceramic sealer group exhibited significantly greater calcium ion release than the calcium hydroxide-treated group (p < 0.01). Despite the significant calcium ion release by the BioRoot cement used to fill the root canal, a lower pH was observed in the external root resorption area compared to the calcium hydroxide-treated group after 7 days. Therefore, the authors concluded that if it is necessary to maintain an alkaline environment for a prolonged period to treat external inflammatory root resorption, the use of BioRoot sealer cannot replace the prolonged application of calcium hydroxide paste for this purpose.

Shim, Jang and Kim (2021), conducted a clinical trial aiming to compare the effects of bioceramic sealer and resin-based sealer on the incidence and intensity of postoperative pain. Patients with anterior or premolar teeth requiring endodontic treatment were directed to Group 1 (n=51), and patients with molars in the same condition to Group 2 (n=57). The groups were subdivided, and the canals were subsequently obturated with Endoseal MTA using the single-cone technique and with AH Plus using the continuous wave technique. Therefore, on the day of obturation, patients were instructed to report pain intensity over 7 days post-procedure, at rest and during biting. After collecting the responses, they found that Endoseal MTA and AH Plus had equivalent effects on the incidence and intensity of postoperative pain. Additionally, less time for obturation was recorded in the Endoseal MTA group compared to the AH Plus group. In summary, the authors concluded that Endoseal MTA used together with the single-cone technique was considered a fast and less painful obturation option.

Montero-Miralles et al. (2021), presented a narrative review aiming to analyze scientific evidence on the application of biomaterials in endodontic microsurgery and their influence on post-surgical tissue repair. They addressed that retrofilling is a crucial step in periapical surgery, requiring an ideal material that seals the root canals, preventing the spread of bacteria and their byproducts. With this, the emergence of calcium silicate-based materials such as MTA revolutionized endodontics, offering biocompatibility, sealing ability, and regenerative potential. Studies indicate that MTA and new bioceramic cements, such as EndoSequence, have positive effects on periapical tissue regeneration and cell adhesion. The use of these materials has been associated with high success rates in endodontic surgeries, especially when combined with microsurgical techniques and magnification with loupes. Furthermore, the application of guided tissue regeneration (GTR) techniques in conjunction with biomaterials, such as PRP, can improve outcomes in cases of large periapical lesions. In summary, they concluded that bone grafts and membranes are not indispensable for complete healing in surgically treated periapical lesions, but may be employed to improve tissue recovery, especially to prevent potential bone collapse. However, MTA proved to be a biocompatible material with cementogenic properties that stimulates periapical healing through regeneration and has contributed significantly to the success of endodontic surgeries. Nevertheless, they noted that further studies are still needed to evaluate new bioceramic cements in conjunction with endodontic microsurgery techniques and long-term follow-up.

Eskandari et al. (2022), addressed in a review article the results of extensive research on the properties and indications of calcium silicate-based cements (CSCs) in endodontics. The study discussed efforts to compile comprehensive data on calcium ion release, bond strength, alkalinizing activity, and bioactivity, as well as the ability to stimulate hydroxyapatite formation as a bioactive characteristic of the cements. The importance of effective sealing was also highlighted as a crucial indicator for the long-term prognosis of root canal treatment integrity, along with other properties such as radiopacity, porosity, and solubility. In addition, clinical applications of cements in vital pulp therapies were reviewed, such as pulpotomy, apexification, and direct pulp capping, as well as their use in root perforation treatments, root canal sealing, and terminal filling. The cements play an essential role in modern regenerative approaches to saving dental tissues, replacing conventional endodontic treatments. In summary, the authors concluded that as a consequence of the favorable properties analyzed in the research, the indication of CSCs use was supported by clinical studies, as well as their characteristics of greater sealing capacity and lower solubility were necessary for the confirmation of their broad spectrum of application in regenerative dentistry. They also emphasized that the continuous development of these materials can significantly modify their physical properties and expand their clinical applications.

Alskaf, Achour and Alzoubi (2022), conducted an in vitro study aimed at evaluating the fracture resistance of endodontically treated lower premolars using different types of cements: EndoSequence Bioceramic (BC), EndoSequence BC HiFlow, and AH Plus (AHP). For this purpose, 75 single-rooted and single-canalled premolars were used, randomly divided into five groups: one with AH Plus, one with EndoSequence BC, one with EndoSequence BC HiFlow, a negative control group (without canal preparation), and a positive control group (with preparation, but without canal obturation). After canal preparation and obturation, the teeth were restored and subjected to fracture resistance tests. The results showed that the EndoSequence BC and BC HiFlow groups showed slightly higher fracture resistance compared to the AH Plus group, but without statistically significant difference between them. The positive control group showed the highest mean fracture force, followed by the cemented groups, while the negative control group had the lowest mean fracture force. In summary, they concluded that the use of EndoSequence BC, BC HiFlow, and AHP improved fracture resistance against vertical forces in treated single-rooted premolar teeth, compared to instrumented but unfilled roots. However, there was no significant increase in root fracture resistance compared to non-prepared canals.

Suwartini et al. (2022), presented an in vitro study aiming to compare the antimicrobial activity of a calcium hydroxide-based cement with two bioceramic cements against biofilms of Porphyromonas gingivalis, Enterococcus faecalis, and Candida albicans. The sealers were dissolved in sterile saline solution to obtain extracts, which were used in biofilm formation assays, colony counts, and real-time polymerase chain reaction (PCR). To evaluate sealer efficacy, biofilm formation tests, colony counts, and real-time PCR were used. The results revealed that the calcium hydroxide-based Sealapex was consistently more effective in eradicating pathogenic biofilms compared to bioceramic cements. Although calcium silicate-based sealers demonstrated stronger antibacterial activity in some aspects, Sealapex outperformed them in most of the tests performed. In summary, the calcium hydroxide-based cement proved more effective in eradicating pathogenic biofilms from root canals compared to bioceramic cements.

Najafzadeh, Fazlyab and Esnaashari (2022), addressed in a laboratory study how two types of cements (epoxy resin and calcium silicate-based) affect sealing accuracy and penetration depth in different filling methods of human premolars. For this purpose, 82 premolar teeth extracted due to dental problems were used. The two types of cements were applied using two filling techniques: lateral compaction and single cone. Sealing accuracy and penetration depth were measured with scanning electron microscopy and laser confocal microscope. The results showed that the bioceramic cement performed better in terms of sealing and penetration than the epoxy resin-based cement in all tooth regions. Furthermore, the filling method did not affect the results. Therefore, based on the results of the laboratory study, the authors concluded that the use of calcium silicate-based cement is more advantageous compared to epoxy resin-based cement, but more studies and filling techniques are needed to ensure adequate three-dimensional sealing in curved root canals.

Mungekar-Markandey, Mistry and Jawdekar (2022), presented a systematic review and meta-analysis aiming to analyze the efficacy of different materials in repairing accidental perforations in primary teeth. The research compared mineral trioxide aggregate (MTA) with other biomaterials for this specific purpose. The results showed that the MTA success rate (80.55%) was lower compared to other materials, such as premixed bioceramics, atelocollagen, and calcium-enriched mixture (96.07%), and this difference was statistically significant (p=0.011). Premixed bioceramics are new materials that have stood out compared to MTA due to their better usability, handling properties, regenerative and inductive properties, and tissue compatibility. Atelocollagen, derived from collagen after pepsin treatment, is considered a suitable biomaterial used in skin and oral membrane reconstruction, as well as applied for hemostasis in extraction sockets. The calcium-enriched cement mixture has a superior antibacterial effect to MTA, releasing calcium and phosphate ions to form hydroxyapatite, even in normal saline solution. These new regenerative materials have overcome the limitations of MTA, such as its granular mixing and prolonged setting time, offering superior induction, proliferation, and stem cell differentiation properties, which improves healing and repair in iatrogenic perforation repair procedures in primary teeth. It was concluded that, within the study limitations, the newer materials are more effective than MTA in repairing accidental perforations in primary molars in terms of clinical success

Zamparini et al. (2022), conducted a study to evaluate the chemical and physical properties and the apatite-forming ability of three premixed calcium silicate-based root canal sealers containing different amounts of calcium silicates. The cements analyzed were Ceraseal, AH Plus Bioceramic, and NeoSealer Flo, compared to an epoxy resin-based sealer (AH Plus). Several parameters were investigated, such as setting time, radiopacity, flowability, film thickness, porosity, water absorption, solubility, calcium release, and alkalinizing activity. After immersion in saline solution for 28 days, scanning electron microscopy, vibrational spectroscopy, and micro-Raman analyses were performed to evaluate apatite formation. The results showed that all sealers met the required standards in terms of physical and chemical properties. Longer setting time was observed for NeoSealer Flo and AH Plus, and shorter for AH Plus Bioceramic and Ceraseal. All materials showed adequate radiopacity and flowability according to the standards. NeoSealer Flo and AH Plus Bioceramic showed higher porosity compared to AH Plus. Ceraseal and AH Plus had the lowest solubility. All sealers released calcium and showed alkalinizing activity. After 28 days of immersion, a mineral layer was observed in all bioceramic sealers, with greater prominence of calcium phosphates in NeoSealer Flo and AH Plus Bioceramic. AH Plus Bioceramic also showed the formation of a thin apatite layer. In summary, the authors concluded that premixed bioceramic calcium silicate-based sealers met the required chemical and physical standards, but showed higher open pore volume, water absorption, and solubility compared to the conventional epoxy resin-based sealer. Furthermore, they emphasized that it is important for professionals to be aware that these materials may have a longer setting time.

Jamleh et al. (2022), conducted a study examining the retreatability of TotalFill (TFBC) and AH Plus (AHP) bioceramic cements, as well as their effects on retreatment force and torque. Twenty-six premolar teeth with single oval canals were used, which were prepared, obturated with each of the tested cements, and subsequently incubated for 6 months. After this period, the canals were retreated with the XP Shaper system, while the generated force and torque were measured. Micro-computed tomography was performed before and after retreatment to analyze the remaining obturating materials in the canals. The results showed that the maximum apically directed force in AHP was greater than in TFBC, while the maximum coronally directed force and maximum torque were similar between the groups. A greater amount of remaining filling material was observed in AHP compared to TFBC. Therefore, they concluded that the type of endodontic cement influenced retreatment ease, with TFBC showing less remaining filling materials and lower retreatment forces in the apical direction compared to AHP in extracted teeth with oval canals.

Khandelwal et al. (2022), systematically reviewed various endodontic sealers in terms of periapical healing, considered crucial for endodontic treatment success. Following PRISMA 2020 guidelines and registered in PROSPERO, PubMed Central and Medline databases were searched up to February 2022 for relevant articles. Studies evaluating periapical healing after the application of different endodontic cements were analyzed, with the primary outcome being the resolution of periapical lesions after endodontic treatment. In vivo studies with a minimum follow-up of 6 months were included. Of the nine clinical studies included in the analysis, four had an overall high risk of bias. However, regardless of the type of cement used, all studies showed significant healing of periapical lesions after endodontic treatment. It was observed that bioceramic and bioactive cements showed better results in terms of periapical healing. Bioactive cements showed better periapical healing compared to zinc oxide and eugenol, although some included studies did not provide high-quality evidence. This aspect needs to be further explored in future trials to provide clear information on all types of root canal cements. In summary, based on the compiled results from the included studies, it can be inferred that bioactive cements showed superior periapical healing compared to zinc oxide and eugenol. However, other types of cements demonstrated results similar to zinc oxide and eugenol in terms of periapical healing during a six-month follow-up period.

Das et al. (2023), presented a case report describing the surgical treatment of a radicular cyst that developed over time due to trauma to three upper anterior teeth of a young adult. After clinical and radiographic examinations, the initial diagnosis of radicular cyst was confirmed by biopsy. Treatment involved performing non-surgical endodontic therapy using Mineral Trioxide Aggregate (MTA) as an apical barrier, followed by surgical removal of the cyst and hydroxyapatite bone graft. MTA showed efficacy in preventing apical bacterial leakage and also stimulated hard tissue formation and cementum regeneration. In this case, MTA was used as a retrograde filling material. Finally, a two-year follow-up demonstrated the success of the treatment.

Sheela et al. (2023), conducted an in vitro study aimed at evaluating the biocompatibility and mineralization potential of two types of bioceramic material, TotalFill BC RRM putty and TotalFill BC sealer, comparing them with an epoxy resin-based sealer, AH Plus, in osteoblast cells. For this purpose, extracts from the materials were obtained and applied at different concentrations to human osteoblast cells. XTT and Alizarin Red S tests were used to evaluate cytotoxicity and biomineralization potential, respectively. The results showed that at high concentrations (100% and 50% extract), all materials were toxic to osteoblast cells. Unlike TotalFill BC RRM putty, AH Plus and TotalFill BC sealer were toxic at the 25% concentration. However, at lower concentrations (12.5% and below), all materials were considered non-toxic. Furthermore, TotalFill BC material demonstrated the ability to promote mineralized nodule formation compared to AH Plus. It was concluded that at low concentrations, TotalFill BC materials were more biocompatible with osteoblast cells, increasing their viability and inducing mineralized nodule formation. However, clinical trials are needed to better understand the long­term effect of these materials in endodontic treatment.

Qiao, Zhu and Pan (2023), presented a study that sought to compare residual endodontic cement based on calcium silicate and epoxy resin on root canal walls after post space preparation, and how this influences the bond strength of fiber posts cemented with dual-cure resin cement. For this purpose, thirty-six extracted single-rooted lower premolars were prepared and randomly divided into two groups. One group received iRoot SP cement and the other received AH Plus. After endodontic treatment and preparation of the fiber post space, cement residues were microscopically examined. The fiber posts were then cemented with dual-cure resin cement, and push-out bond strength was measured in each third of the post space. Fracture modes were also evaluated. Statistical analysis used independent sample t-tests and one-way analysis of variance. There was no statistically significant difference in the bond strength of fiber posts between the two groups. However, sealer residue was observed in 38.9% of the samples treated with iRoot SP, while no samples treated with AH Plus showed this residue. The main failure mode in iRoot SP samples was adhesive failure between the resin cement and the post, without adhesive failure between the cement and dentine at the sealer residue site. Thus, the authors concluded that finding iRoot SP cement residue after preparing the post space does not significantly affect the adhesion of fiber posts to dentine. Therefore, using iRoot SP with the single-cone technique is a practical choice for sealing the root canal before cementing the fiber post.

Shaik et al. (2023), conducted a systematic review aimed at comparing the success rate of three different materials for apexification of permanent teeth: Endosequence (BCRRM), mineral trioxide aggregate (MTA), and calcium hydroxide. Indexed journals such as Google Scholar, PubMed, Scopus, Cochrane, Research Gate, Wiley Online Library, and others were searched from inception to November 2020. Articles were selected based on PRISMA guidelines. Of 410 identified studies, 150 were selected after title/abstract assessment. After full-text reading and application of inclusion and exclusion criteria, nine studies were chosen for the systematic review. Clinical and radiographic success rates, as well as the time required for apical barrier formation, were reviewed. All three materials showed nearly similar clinical success rates, but MTA and Endosequence BCRRM proved superior to calcium hydroxide in terms of time required for apical barrier formation and single-visit treatment. However, comparative studies between Endosequence and MTA are limited and require additional evaluation in the future.

Pereira et al. (2023), addressed in a report of two cases the assistance of calcium silicate-based cements in the remineralization of osteolytic lesions in endodontic-periodontal diseases. Bioceramic cements used to fill root canals in cases of endo-perio lesions of endodontic origin show promise in promoting faster and more predictable healing of periapical lesions, as they have the ability to stimulate osteogenesis. An effective treatment plan depends on precise diagnosis of the endo-perio lesions, identifying the origin of the infection, whether in the root canal, the periodontium, or both. In both reported cases, no clinical signs of periodontal disease were observed, such as bleeding or calculus, but primary endodontic lesions with potential for drainage through the gingival sulcus were identified. In addition to the disinfection strategies employed during the endodontic treatments, the calcium silicate-based cements Bio C Sealer, Bio C Repair, and Bio Root RCS were used to fill the root canals. Both cases showed remarkable bone gain at 8 months for case 1 and 5 months for case 2. In case 1, an apical plug with bioceramic repair cement was used in the palatal root canal. Based on the reviewed literature, the authors concluded that after appropriate disinfection of root canals, the use of calcium silicate-based cements for filling these canals demonstrates potential to assist in the remineralization of bone lesions in endo-perio diseases.

Fonseca et al. (2023), presented a study that sought to compare a bioceramic endodontic cement and a resin-based endodontic cement regarding extrusion and postoperative pain. Sixty-four patients requiring endodontic treatment of single-rooted maxillary teeth with necrotic pulps were included. Treatments were performed in a single visit, using a single-canal system size 40.06, with 2.5% NaOCl irrigation. After irrigation with 17% ethylenediaminetetraacetic acid (EDTA) and 2.5% NaOCl, the canals were randomly divided into two groups: resin group (RG), filled with AH Plus, and calcium silicate-based group (BG), filled with Sealer Plus BC. Ibuprofen (600 mg) was prescribed every 6 hours for pain. Patients recorded their pain on a visual analogue scale (VAS) at 24, 48, 72 hours, and 1 week. In summary, the authors concluded that the bioceramic sealer showed more extrusion than the resin-based sealer, but extrusion was not associated with pain. Pain level and analgesic use were similar in both groups.

D'Amico and Rodríguez (2024), this study aimed to evaluate how these cements behave in terms of sealing and intratubular penetration, using hot and cold obturation techniques. After a search in databases such as PubMed, Scopus, and Web of Science, 16 articles were selected up to February 2023, of which 10 were included in a meta-analysis. Of the selected articles, four addressed intratubular penetration, four sealing ability, and two both variables. The analysis revealed that hot obturation resulted in significantly greater intratubular penetration compared to cold obturation, with sealing ability also superior, approaching statistical significance. In summary, hot obturation proved to be more effective in terms of penetration into dentinal tubules and sealing, with a statistical trend toward superiority over cold obturation.

Bhasin et al. (2024), presented a case report describing the non-surgical treatment of an anterior tooth with a canal that has divergent, funnel-shaped walls and an open apex, using mineral trioxide aggregate (MTA) with magnification. When the pulp is traumatized before root formation, pulp necrosis can occur, interrupting the development of dentine and the root, leaving the canal wider due to the fragility of the dentinal walls. Therefore, the authors opted for apexification with MTA to create a hard tissue apical barrier, being a predictable and superior option to the use of calcium hydroxide. In the described case, a new technique was employed to place MTA in the right upper central incisor of a 9-year-old female patient, using a micro-apical placement system under a dental surgical microscope. After confirmation of MTA hardening, obturation was performed with calcium silicate-based cement and gutta-percha, followed by post-endodontic composite resin restoration. In conclusion, apexification is the appropriate management for the treatment of an immature non-vital tooth with a widely open apex, as it is faster, more predictable, and provides immediate results. The use of MTA, bioceramics, and magnification are considered recent advances in the treatment of teeth with immature apex, contributing to addressing this endodontic challenge.

DISCUSSION

The main functions of filling cements are to seal spaces, accessory canals, and multiple foramina, create a bond between the filling material and the canal wall, and act as a lubricant, facilitating the placement of the filling core and eliminating remaining bacteria. Due to their importance, the chemical and physical properties of these sealers have been extensively studied since the beginning of the 20th century (Al-Haddad e Che AB Aziz, 2016).

According to Palczewska-Komsa et al. (2021), setting time should be less than 10% of the time specified by the manufacturer. Furthermore, Eskandari et al. (2022) states that the setting time of bioceramic cements ranges from 40 to 120 minutes, which is considered long for some applications, where an ideal setting time would be between 3 and 10 minutes. However, Zamparini et al. (2022) analyzed the initial and final setting time of three calcium silicate-based cements — Ceraseal (Metabiomed, South Korea), Neosealer Flo (Avalon Nusmile, USA), and AH Plus Bioceramic (Maruchi, South Korea) — evidencing a variation in initial setting time from 60 to 480 minutes and final setting time from 660 to 1344 minutes. Therefore, these data indicated that the setting times of all calcium silicate-based sealers were considerably longer than those reported by the manufacturers. Al-Haddad and Che AB Aziz (2016) point out that the normal setting time is around four hours, however, in patients with moist canals, the setting time can be considerably longer. The amount of moisture present in the dentinal tubules of the canal walls can be affected by absorption with absorbent paper points.

One of the relevant characteristics of endodontic treatment is the formation of mineralized tissue. Eskandari et al. (2022) stated that particles produced by ionic dissolution are seen as essential components in the biological activities of calcium silicate-based materials. Increased levels of calcium and silicon ions can provide favorable conditions for the development and differentiation of osteoblasts, as well as generating high pH environments, which intensifies periapical healing processes. Furthermore, Palczewska-Komsa, Kaczor-Wiankowska and Nowicka (2021), conducted a study which showed that MTA HP (Angelus) releases calcium more intensely in the first month after application, compared to conventional MTA (ProRoot MTA, Dentsply Sirona), which showed greater calcium release after 1 week. Thus, they reaffirmed that the ability of MTA to form hard tissue can be attributed to its Ca2+ release and the creation of an alkaline pH. Das et al. (2023) reaffirmed previous findings by showing that MTA stimulates regeneration of new cementum. Furthermore, Retana-Lobo et al. (2021) evaluated that powder-liquid calcium silicate-based sealers (BioRoot and ProRoot) showed greater bioactivity regarding alkalinization potential and calcium ion release compared to the paste-format calcium silicate-based sealer EndoSequence. On the other hand, Sheela et al. (2023) showed that although the high pH of the material has a beneficial effect in enhancing its antimicrobial action, it can also cause DNA damage and denature proteins from other cells. However, at lower concentrations, it demonstrates a positive impact on cell viability.

Adequate sealing and obturation of the root canal system, after cleaning and shaping, are crucial steps that can influence the long-term success of endodontic treatment. Wang, Liu and Dong (2018), conducted an in vitro study aiming to analyze the penetration capacity into dentinal tubules and filling quality of calcium silicate-based cement IRoot SP compared to epoxy resin-based cement AH Plus. This study concluded that, regardless of the obturation technique used, bioceramic cement showed superiority in both addressed topics. In another study, Candeiro et al. (2019), compared the filling capacity in simulated lateral canals of bioceramic cement Endosequence BC Sealer and AH Plus, epoxy resin-based. It was concluded that the filling capacity was similar and that the technique used did not interfere with the result; however, the diameter of the canals influenced the performance of the bioceramic, which penetrated more easily in larger diameter canals. Najafzadeh, Fazlyab and Esnaashari (2022) reaffirmed the conclusion of previous studies, in a study using the same cements as Candeiro et al. (2019), and added that the greater penetration capacity of the calcium silicate-based sealer is due to the smaller particle size when compared to the epoxy resin sealer, thus also acting as a physical barrier to prevent microleakage of the root canal system. However, despite previous studies stating that the obturation technique did not interfere with results, D'Amico and Rodríguez (2024) showed in their systematic review that the hot obturation technique (Tagger's hybrid technique) showed greater sealing capacity and penetration compared to the lateral condensation technique.

The use of bioceramic cements extends beyond root canal obturation. Although calcium hydroxide is conventionally used for direct pulp capping, Mineral Trioxide Aggregate (MTA) is being considered as the first choice for this type of procedure. Al-Saudita et al. (2019) conducted a comparative study between two calcium silicate-based cements — TotalFill and Neo MTA Plus — both used as direct pulp capping agents. After three months of observation, it was concluded that both cements stimulated the formation of a dentinal bridge without generating pulp inflammation, confirming their biocompatibility and bioactivity characteristics, as well as sealing ability and antimicrobial efficacy. As disadvantages, they presented difficulty in handling and long setting time.

In endodontic practice, adverse events and complications, such as root perforation, require the use of biocompatible materials that promote tissue repair. Toubes et al. (2021), observed that in this scenario, mineral trioxide aggregate (MTA) has traditionally been the choice for endodontic repairs. However, Bio-C Repair, a new bioceramic material in ready-to-use format, offers improvements in handling and insertion, contributing to clinical practice and saving time. The study showed that this material has cytotoxicity, biocompatibility, and biomineralization properties similar to MTA-HP and white MTA, but presents greater cell viability and adhesion. Mungekar-Markandey, Mistry and Jawdekar (2022), consolidated the conclusions of the previous study, citing that premixed bioceramic cements have been preferred over MTA, due to handling and regenerative properties, as well as inductive properties and tissue compatibility, in addition to usability. The new calcium silicate-based materials have shown improvements in their properties compared to MTA, in the areas of handling, setting time, and cost-effectiveness. Von Arx et al. (2020) reaffirms the thesis, using Endosequence cement in endodontic surgeries as an example, highlighting its ease of handling and application compared to MTA, in addition to having similar levels of toxicity.

When conventional endodontic treatment does not achieve its objectives and the periapical lesion persists, endodontic surgery, especially microsurgery, may be indicated. Retrofilling is essential in this surgery, as the ideal material must seal the root canal and prevent the extrusion of bacteria into the periradicular tissues. Montero-Miralles et al. (2021), evaluated patients 5 years after being submitted to periapical microsurgery using three types of retrofilling materials: MTA (calcium silicate-based), Super-EBA (zinc oxide and eugenol-based), and Retroplast (composite resin-based). The success rate obtained was 75.9%. The study concluded that the healing rate was considerably higher using MTA as the retrofilling material, as it is associated with better periapical repair responses than other previously developed materials, due to stimulation of periodontal and gingival fibroblast differentiation in cultures, increasing alkaline phosphatase levels, as well as cell adhesion and proliferation.

Calcium silicate-based cements can also be used for root canal obturation in cases of endo-perio lesions of endodontic origin. Pereira et al. (2023) reports that the endo-perio lesion is a pathology that simultaneously affects pulpal and periodontal tissues; in the endodontic treatment of this lesion, efficient disinfection of the root canal system and its complete sealing are essential for treatment success. The authors reported two cases of endo-perio lesions, which were obturated with two different bioceramic cements — BioC Sealer and Bio Root RCS. Therefore, the choice of this class of cements for root canal obturation in cases of this lesion appeared promising due to evidence pointing to the potential of these materials in promoting rapid periapical lesion healing, due to their capacity to support remineralization, stimulating osteogenesis. After eight months of follow-up, they reported bone gain above expectations. Therefore, they concluded that calcium silicate-based cements should be indicated as the first option for this type of treatment.

Non-surgical endodontic retreatment seeks to eliminate bacteria from the root canal system, correcting pathological or iatrogenic defects and preventing new ones. Jamleh et al. (2022), observed in the findings evidence that the type of endodontic cement used in initial treatment significantly affects retreatment parameters, as they create resistance in the canal walls, resulting in greater force and torque application. The authors showed in the study in question that roots obturated with TotalFill (bioceramic) showed less apical force and less remaining filling material, in addition to recovering apical patency in all roots, compared to AH Plus (epoxy resin-based), which required greater apical force.

Fiber glass posts are recommended to ensure retention of teeth that have undergone extensive coronal destruction and have been endodontically treated. Qiao, Zhu and Pan (2023), state that filling cements can be difficult to remove from dentinal walls and can also reduce bond strength. The study revealed that it was difficult to completely remove excess iRoot SP from the root canal system after preparing the post space, while excess AH Plus (epoxy resin-based) could be removed more easily. The iRoot SP was found mainly in the cervical and middle regions of the root canal. Although previous studies suggest that iRoot SP may negatively affect the bond strength of fiber posts, this study found no differences in post bond strength between both cements. Post retention depends more on adhesion between the cement and the post than between the cement and dentine. Despite cement residues, this did not significantly impact the bond strength of fiber posts. Thus, it was concluded that iRoot SP used with the single-cone technique is a viable option for root canal obturation before fiber post cementation.

Apexification is an appropriate technique to treat non-vital immature teeth with open apices, as it is efficient and produces fast results. This technique aims to create a rigid apical barrier in permanent teeth with open apices. Bhasin et al. (2024) states that, traditionally, calcium hydroxide was used for apexification, but presents challenges such as imprecise treatment time and unpredictable apical closure. Modern bioactive materials, such as mineral trioxide aggregate (MTA), have shown significant advantages, including the ability to form an effective three-dimensional seal, antimicrobial properties, and stimulation of cementogenesis and osteogenesis. On the other hand, Shaik et al. (2023), showed that although MTA has proven to be a promising material for apexification, it has some disadvantages, such as discoloration and weakening of dentinal walls. Furthermore, Khandelwal et al. (2022), reported that an MTA cement has the ability to block and prevent any apical fluid flow and achieve a more stable and durable seal than traditional cements containing zinc oxide and calcium oxide, as well as playing a fundamental role in minimizing acute inflammatory responses.

Shim, Jang and Kim (2021), conducted a comparative study between two cements — bioceramic (EndoSeal MTA) and epoxy resin-based (AH Plus) — and no statistically significant difference was found in the incidence of pain between the cements during the seven days following canal obturation. Furthermore, Fonseca et al. (2023), in their studies suggested that the bioceramic sealer, Sealer Plus, showed a higher extrusion frequency than the resin-based sealer, AH Plus. However, extrusion had no association with pain. The mean pain level was similar in both groups. The present study had no crisis reports, and the majority of patients reported no pain at any time interval, regardless of the cement used.

Longitudinal fractures in endodontically treated teeth are a frequent complication. Almohaimede et al. (2020), compared the fracture resistance of teeth treated with bioceramic cement (TotalFill) and epoxy resin-based cement (AH Plus). They concluded that the type of cement did not interfere with fracture resistance and, therefore, did not reinforce teeth with endodontic treatment. On the other hand, Alskaf, Achour and Alzoubi (2022), performed the same comparison, changing only the calcium silicate-based cements, with EndoSequence and HiFlow being chosen. They found that there was no significant difference in resistance between the sealers; however, there was indeed an improvement in fracture resistance when compared to instrumented but non-obturated teeth. In both studies, a single vertical force was applied.

Suwartini et al. (2022), conducted a study comparing the antimicrobial activity of three filling cements — two calcium silicate-based (BioRoot RCS, Sure-Seal Root) and one calcium hydroxide-based (Sealapex). These sealers were exposed to three microorganisms: Porphyromonas gingivalis, Candida albicans, and Enterococcus faecalis. Raghavendra et al. (2017), points out that bioceramic cements exhibit antibacterial and antifungal activity, which are characteristics arising from the alkaline pH, according to Retana-Lobo et al. (2021). However, despite these facts, in the study by Suwartini et al. (2022), the results indicated that the calcium hydroxide-based cement was more effective against all pathogenic biofilms, but without negating the existing efficacy of bioceramics.

According to Alskaf, Achour and Alzoubi (2022), calcium silicate-based cements release calcium hydroxide during the hydration process, which influences water absorption and solubility more significantly compared to conventional resin-based cements. According to Palczewska-Komsa, Kaczor-Wiankowska and Nowicka (2021), solubility should not exceed 3% of the material mass. A study by Angkasuvan et al. (2021), showed that BioRoot sealer had less than 3% mass loss, but still showed high solubility before setting time, which decreased significantly after setting, but was not absent. Eskandari et al. (2022) points out that constant solubility ends up affecting the sealer's ability to prevent apical leakage, and demonstrated that AH Plus sealer showed lower solubility compared to bioceramic cements, and this theory was also confirmed by Sheela et al. (2022), in their study. Palczewska-Komsa, Kaczor-Wiankowska and Nowicka (2021) explains that pores are formed both on the surface and inside the material, which weakens the cement structure and makes it vulnerable to the action of solvents, facilitating water absorption.

CONCLUSION

It was concluded from this research that bioceramic cements in endodontics are widely valued for their biocompatible properties, tissue regeneration potential, and effective sealing capacity, promoting periapical healing and bone repair. However, a negative point is their solubility, which can compromise sealing durability over time, increasing the risk of microleakage. Despite this, their versatile applications — as repair and filling cements — continue to be great advantages in endodontic treatment.

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¹ In accordance with the Normalization Manual for TCCs and Monographs of the São Leopoldo Mandic Group of 2024, based on the Vancouver style, and abbreviation of journal titles in accordance with the Index Medicus.