Root End Filling Materials

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Endodontics & Dental Traumatology

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Review article
Root end filling materials: a review

Torabinejad M, Pitt Ford TR. Root etid filling tnaterials: a review. Endod Dent Traumatol 1996; 12: 161-178. Mtmksgaard, 1996 Abstract-When non-surgical attempts pixnv tiusticccssiul or are couti aindicated, sttrgical endodontic therapy is needed to save tbe tootb. Tbe procedute usually consists of ex]Dosure of tbe involved area, root end lesection, root end piepaiation and insertion of a root end fiUing material. Nunietotts materials have beet! suggested as root end filling materials. This article is a review of tbe literattne on tbe suitability of variotis root end filling liiatet ials based ou tbeir leakage assessment, marginal adaptatioii, cytotoxicity, and usage test iii expetiniental animals and Innnans.
M. Torabinejad\ T. R. Pitt Ford^
'Department ot Endodontics, Loma Linda University, Calitornia. USA, 'Departmet ot Restorative Dentistry, United Medicai and Dental Schools, University ot London, England
Key words: root end tilling; retrograde tiiling; endodontic materials Mahmoud Torabinejad, Department ot Endodontics, Loma Linda University, Loma Linda, Calitornia, USA. Accepted January 8,1996
Studies have shown that pulpal and periiadicular patbosis develop only when tbese tissties are exposed to bacteiial contamination. To determine tbe impoitance of bacteria, Kakebasbi et al. (1) as well as Paterson (2) exposed tbe dental ptilps of ccinventional and germ-free rats to tbeir own oral flora, wbicb resulted in tbe development of pulpal and ]:)eritadictilar lesions in conventional tats, but failed to create lesions in germ-free rats. Moller et al. (3) severed tbe pulps of teeth in tnonkeys and eitber sealed aseptically the amptitated pulps immediately, or left them open to be contaminated with indigenotis oral flora for 1 week and then sealed. Clinical, radiograpbic, and bistological examinations of tbe teeth tbat were sealed aseptically showed an absence of any patbological changes in their peritadicttlar tissues. In contrast, teetb witb infected root canals had inflammatory reactions in their tissues. Fabticitis et al. (4) inoculated root canals of monkeys with 11 bacterial species sejDarately, or in combinations, and sealed tbe access cavities for a period of 6 tiiontbs. Tbeir bacteriological and bistological examinations showed tbat mixed infections have a gieqter capacity to cause apical lesions than do monoinfections. Fttrtberniore, the)' reported that the Bacteroides strain did not survive in tbe root canals when inoculated as ptue
cultures. Enterococei sur\ived as ptue ctiltures, and facultative streptococci induced small petiiadicular lesions. As a consequence of patbological changes in tbe dental pulp, the root canal system acquires tbe capacit)' to harbour several species of bacteria, tbeir toxins and tbeir by-products. Egress of these irritants from the root canal system into tbe periapical tissue restilts in tbe formation of periradicular lesions which are mediated by nt)nspecific as well as immtme responses (5). Complete cleaning and shaping of root canals and sealing tbem in tbree dimensions sbould resttlt in resoltition of periradicttlar lesions in all patients wbo have undergone non-surgical root canal therapy. Tbe degree of sticcess follo\dng root canal therapy has been reported as bigb as 98.7% (6) and as low as 45% (7). Ingle & Glick (8) reported a success rate of 95% of all treated endodontic cases, wliich compares favotirabh- with otber reports of success. In an examination of failed cases from the Washington study Itigie et al. (9) reported tbat over two thirds of tbese failures wete related to incomplete cleaning atid obttiratiou of root canals. Harty et al. (10) bave also reported tbat the majority of non-stirgical endodontic procedtues wbicb fail do so because of inadeqtiate apical seal.
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Itl addition to the factors cited in tbe above studies, a number of recent investigations bave sbown tbat the exposttre of the coronal pat ts of filled root catnals to oral flora tesitlts in total contamitiation of the filled t oot canals in a few days (11-1.5). This occttrs as a restilt of either the presence of voids between tbe deutinal walls and tbe filling materials used to ot:)tuiate tbe root canal .system and/or "wasbitig otit" of tbe toot canal sealers. Tbe preferted treatment of failing etidodontic cases is non-stngical retreatnient. According to Bergenboltz et al. (16) tbis treatment usually tesults itl successful outcomes. Howevet, becaitse of tbe complexity of root canal systems, inadequate itistitmientatiou and presetice t)f pbysical barriers (anatomical, post atid core restoration, separated instrimients, etc.), ideal goals tiiay be difficult to acbieve witb a non-surgical approach. Surgical endodontic therapy then becomes tbe fiist altetnative. Endodontic stngery lias a lotig bistoty. Tbe procedure involves expositig tbe involved apex, resecting the root-end, pi eparing a class I cavity, and most often inserting a root-end filling material. Because most endodontic failures occur as a testilt of leakage of irritants from pathologically involved root canals the root-end ftlling tnaterial sbould ptovide an apical seal to an otbei wise unobtttrated root catial or improve tbe seal of existing root canal filling materials and be biocompatible witb periradictilar tissties. To seal the root-end, the operator should remove the apical 2 3 mm of the root-end, prepare a root-end cavity, atid place a root-end filling matetial. A bevelled resected root is crttcial to good visibility (17). However, Gilheany et al. (18) demonstrated that as tbe angle of tbe bevel increases, the apical leakage also increases due to tbe permeability of tbe dentinal tubules. After a toot resection, as perpetidictilar to tbe lotig axes of tbe root as possible, a class I cavity preparation wbicb incltides tbe apical foramen of the root should be prepared witb a bur or an idtiasonic instrument. Despite tbe advantages of tilttasonic tips sbown by Wuchenich et al. (19), Abedi et al. (20) bave demonstrated tbat tbey cteate more iiiicrofractures tban bins during toot-etid pleted, a suitable root-end filling material must be cbosen. According tc:) Cartner & Dorn (22), an ideal tnaterial to seal tbe root-end cavities sbould prevent leakage of microorgatiisms and tbeir byptoducts into tbe petitadictilar tissues. It sbould also be non-toxic, non-carcinogenic, atid biocompatible witb tbe bost ti.ssttes. In addition, it sbould i e iusoluble in tissue flttids atid dimetisiotially staD ble. The presence of moistute should uot affect its sealing ability. For practical putposes it sbould also be easy to ttse and be radiopaque to be recogtiized on tbe radiogiapbs. Numerous materials bave been suggested as toot-end lilling materials: gutta-petclia, amalgam, polycaiboxylate cements, zinc pbospliate cements, zinc oxide eugeiiol paste, IRM cement, EBA cement, Cavit, glass ionomers, composite tesiiis, atid otber matetials sucb as gold foil and leaf, silver ]Doints, cyanoactylates, polyFlEMA and bydton, Diaket root canal sealet, fitanium screws, and Tefion (23). Tbe suitability of root-end filling materials lias been tested by their leakage assessment, matginal adaptation, cytotoxicity, and tisage test in experimetital atiimals and man. I. Leai<age assessment The qtiality of apical seal obtained by toot-end filling materials bas been assessed by the degrees of dye, ladioisotope or bactetial penettation, electrocbemical tiieans, and fluid filtration technique (24-67). A. Particle ieai<age Tbe results of tbese stuches sbow tbat various alloys leak differently and conventional alloy leaks significantly less than otber t)'pes (27). Amalgam by itself does not prevent penettation of various tracets and its .seal improves by addition of vatnisb (31, 3,5, .51, 55, 62). In contrast to tbese findings. King et al. (58) and Olsoti et al. (59) found no sigtiificant diffeience in leakage of amalgam witb and withottt applicatioti of a cavity vat nish. SzetetnetaBrower et al. (34) showed good apical seal with ajiicoectomy alotie while Kajalati et al. (30) detiionstrated inferior seal witb apicoectomy aUjne cotnpared witb beat or cold btttnisbed giittapercba. However, Bramwell & Hicks (37) reported no significatit difference between tbe amount of leakage of root-end resected teetb wben cotn|3aied with those of hot atid cold btnnisbed gittta-]:)etcba or root-end cavities filled with amalgatn. Becker & Voti Fraittihofer (48) showed that the seal of thetmoplasticized gutta-percha withottt a root catial
cavity preparations. Recently, O'Conner et al. (21)

compaiecf tbe sealing ability of SuperEBA and anialgatn with varnish when placed into cavity prepatations made witb ulttasonic tip or fissure bur. Their resttlts showed uo sigtnficant diffetence between tbe two root-end resections and prepatation teclniiques. Howevet; tbey sbowed Sttpei EBA leaked significantly less tban amalgam witb varnish. Once tbe loot-cnid pre]3atation lias been com-
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Root end filling materials

sealei' was worse thati that with a sealer atid atnalgam with varnish. Woo et al. (57) also showed that tltermo])lasticized gutta-percha with sealer had significautl)' less leakage than amalgatn wben used as a toot-eticl filling material. Olson et al. (59) also fotmd tbat injectable bigb-tetiiperatitte gtutapercba witbout sealer demoustrated sigtiific antly more leakage tban tins matetial with a sealer, a glass iotiotner cetiic^nt and amalgam with atid withoitt vatnisli. Kîplan et al. (30) tejjorted itnprosx'd sealability of gutta-percha after cold btnnisliiug of tbis material, and Minnicb et al. (52) noted beneficial effects of cold btttnisbing for poorly obtutated canals. Otber invesfigatots (34, 39, 41, 51), bave repot ted no improvetiient in sealing ability of gtttta-petcba fbllowitig cold burnisbiug. A nutnbet of investigatots bave teported tbat heat bttt nishing of gittta-petcba does not inipro\e tbe sealitig abilit)' of tbis substance as a root-end filling material (30, 34, 39, 44, 46). Bramwell & Hicks (37) tejjorted no significant difference between dye leakage of beat or cold burnislied gutta-petclia in monkeys. In contrast, Abdal & Retief (28) sbowed that heat sealed gtttta-petcba ptovided a better seal tban most comtnonly used root-end filling tnatetials sttcb as atnalgam, IRM and SttjjetEBA. MacPberson et al. (47) as well as Wii et al. (56) and Woo et al. (57) teported obtainitig a better seal witb tliernioplasticized gutta-percba tban amalgatn witb and witbout \'arnish. In contrast Escobar et al. (3()) atid Olsoti et al. (59) reported equal sealing ability for tbertnoplasticized gutta-petclia atid atnalgam witb atid without varnisb. Because amalgam and gtttta-petcba fail to provide ideal apical seal, otber substances sticli as ZOE based cements, glass ionomets, composites and otber substances bave been suggested as rootend filling materials. Some investigators (28, 43, 45, 49, 54, 60, 61), sbowed tbat glass ionomer cements ptovide better seal tban atnalgatn. In contrast. King et al. (58) showed tbe seal pto\ided by Ketac-silver was itiferioi- to tliose obtained by SuperEBA, and amalgam witb and \vitbout varnisb. In additioti, MacNeal & Beatty (40) deniotistrated tbat tbe seal of two glass ionomers (Ketac and Ftiji II) was adversely affected wben the root-end cavities were contaminated with moisture at the time of placetnent of these materials. Abdal & Retief : (28), McDonald & Ditmsba (39), Thirawat & Edmunds (54) and Danin et al. (63) reported that composite resins provided better seal than tbat obtained with amalgam. Szeremeta/Brower et al. (34), and Bondia et al. (50) tepotted that StiperEBA iîovided a better seal compared witb amalgam as a root-end filling tnatet ial. Howevet; otber itivestigatots (44, 51, 54, 58, 66) ba\e sbown tbat Su]3et EBA provided eqttal seal to atnalgam in cotijitnctiou witb a cavity xarnisb. Abdal & Retief (28), Sniee et al. (42), and Boiidta et al. (50) sbowed tbat IRM provided a better seal tbati amalgam or SnperEBA. Bondta et al. (50) slitnved tbat SupetEBA's seal was equal to that oflRM. Conipat iug- the data obtaitied frotn vat ious leakage studies sliows considerable variations in tbe results of these in\'estigations and even witbin tbe same group of studies using similar experimental tnetliods. The data genet ated in most of these studies were collected after longitudinal or cioss sectioning, or clearing ofthe roots, and measuring the linear ttacer penetratioti. These studies pto\lded setni-qnatititati\e data atid lia\'e a high level of variation. In addition to the fact that dye or isotope penettatioti studies do not pro\'ide the volume of tt acet s which penetrate through the interface between lt)otb structtires and root-end filling materials, otber vatiables, sucb as molecular size of ttacer, immetsion petiod, pH of ttacer sohitioii and etitiapped air, bave not been standardized. Ketsten & Mooter (68) compared tbe ability of four obttttation metliods to pie\ent leakage of bacteria-sized particles or large protein tnolectiles, and found leakage of tbe commonly used dye, metliyleue blue, was coniparalile witb tbat of a small bacterial metabolic product of similar tnolectilar size. Tbeir findings sbowed tbat microleakage of tbe small molecules could not be prevented, wliile leakage of bacteria-sized pardcles and large si/e jjtoteiti niolectiles could be prevented witb sotiie of tbe obttnation teclniiques. Higa et al. (67) evaluated the influetice of storage finie (0 versus 24 bout s) ou the atnount of dye leakage of amalgam, SuperEBA, or IRM. Their results showed SuperEBA and IRM leaked significantly less than amalgam and storage time bad no significant infiuence on tbe amount of dye leakage. Altbougb pH of tracer sohuicMi may affect the leakage pattet n of root-end filling materials, it is interesting to note that most studies did not give the pH of tbeir solntions. Tbe gap betAveen root-end cavity walls and rootend filling materials may contain air and/or fluid. C.ofdiiian et al. (69), Spangbeig et al. (70) as well as Oliver & Abbott (71) sbowed that the tise of a \acitutii increased tbe amount of dye penettation. However, recetit studies by Petets & Harrison (72) as well as Masters et al. (73) questioned tbe beneficial effects of this procedtire in leakage sttidies. Tbe majority of leakage studies bave been perfbtniecl ill r'/7?mvitb little or no similarities to conditions in x>iv(). One ol tbeir major limitations is the atnoittu of flttid rxcbange between the apical
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toot canal walls and tbe root-end filling material. Tbe amount of tissue fitiid presetit iu tbe apical regioti is tnttcli less in xrivo cotnpared witb in xriiro tests. In addition, most in vitro studies bave been perfotined in dry conditions wliich do tiot detetmine the advetse effects of humidity oti diese matetials. Tbe sealing ability of some of tbe toot-end fillitig materials, sncb as glass ionotiier ceinetits, can be adversely affected by tbe pt esence of moisture as sbowti by MacNeil & Beatty (40). Dye penettation tecbnique is tbe most freqtteutly tised tnetbcid to evaluate tbe sealitig ability ol variotts root-end fillitig tnaterials. Autoradiogtapliy is a subjective Cjuantitative tecbtiiqite of tneasttring tbe apical leakage. Factot"s sticb as type of isotope, distance between tadiadon source and etnnlsion, and the length of exposute of the fihn can affect the results obtained by tbis tecbnique. Matloff (74) showed that niethylene bltie dye penetiated further up tbe canal tban ''(ia, ' 'Olabelled utea, or '^Î-labelled albumin, and questioned tlie validity of tbe results obtaitied in tadioisotope studies. Delivanis & (]baptiian (75) cotnpated tbe reliability of tbe electrocbemical method, atitoradiography and dye penett ation for leakage assessment. They concluded that the correlation between these tiiethods was correct at the two extreme etids of the scot e ratiges. Tbey stated tbat dyes at e simplei; cbeaper, safet; atid easier to handle tban radio-isotc:)pes. Tbe leakage assessmetit does not recjtiire a special set-tip cotnpated with tbat needed for tbe electrocbemical metbod. It is also possible to obtain false leakage otber tban irotn tbe apex witb tbe electrocbemical method. Tbe majotity of in vitro apicoectotiiies bave been performed pet pendicular to tbe long axis of the teeth, in conttast to a 45 degree lingtio-buccal bevels ofteti used in cotiditions in viiio. Bevelling of the root surface at an angle results in exposure of dentinal tubules. Tbese ttibtiles may provide additional patbways for leakage. Cillieany et al. (18), usitig a fluid filtration tecbnique, determined tbe apical leakage of extracted teetb resected at 0, 30, and 45 degress to tbe lotig axis of tbe root and filled the root-end cavity with various increments of a glass ionomer cemetit. Their results indicate that apical leakage significantly increases as tbe amoLtut of tbe bevel increases. In addition, tbey sbowed tbat increasing the thickness of root-end filling materials significantly decreased tbe apical leakage. Tbe tbickness of toot-end filling tnaterials is anotlier uncontrolled variable in leakage sttidies and has varied from 1 to 5 mm (28, 31, 35, 76-78). Finally, most apical leakage studies bave detet-mined the sealing ability of various tnaterials by placing the apical ends iti the ttacets. Pracfically, the purpose of placing a root-end filhng material is to prevent penettatioti of itritatits fVom the root canal system into periradictilar tissues. In reality, cotonal seal of toot-etid filling tnatetials is jirobably mote importatit tban tbat of tbe apical seal. King et al. (58), Ctooks et al. (64), Gilbeany et al. (18), and MacDonald et al. (66) used tbe fluid filttation tecbniqtte develojjed by Derkson et al. (79) to determine tbe leakage ]3atterns of vat ions root-etid fillitig tnatet ials. Tbe tnain advantages of this tecbnique are: 1) the sam]:)les are not destroyed 2) the leakage can be detet tnined at diffetent time intetvals and 3) tbe collected data is quantitative. However, applicatioti of solution ttnder pressttre does not simttlate clitiical cotiflitiotis.
B. Bacterial leakage
Despite tbeir ijopitlarity atid ease of tise, tbe t esttlts atid clinical sigtiificatice of leakage sttidies bave been questioned (14, 80-84). Mortensen et al. (80) and Ktakow et al. (81) sbowed fliat microotganistii jDenetration tnight be more approjjiiate tliati dye or isotojDe penetration for stttdying leakage in vitio. Goldtnan et al. (82) bave pointed out tbat bactetia gi\e better itidicatioti tbati dye iti testing for leakage of bydrophilic materials atid that dyes cati gi\e a false positive leading if tbeir tnolectiles were stnall etioitgb. Torabitiejad et al. (14) used two species of bactet ia, Stnphylococcus cpidcrmidis and Proteus viitgaris, tc:) evaluate the coronal leakage of root canal-filled teeth. Eighty-eight percent of tbe root canals were completely recotitaminated in 30 davs following exposures to Stapliylococrus epidermidis and 85% in 66 days following expcjsure to Proteus vulgaris. Magitta et al. (15) evaktated tbe coronal leakage in obturated root canals using fresb liutnan saliva. Tbey found that salivaty leakage was slc:)wer than dye penettation. They also reported that salivary penetration at 90 days was significanfly greater than that seen after 2, 7, 14, and 28 days. Kliayat et al. (83) detertnined the time needed for bacteria in saliva to contaminate tbe entire length of obturated root canals and found all root canals were recontaminated in less than 30 days. Wti et al. (84) used tbe movement of a bacterium (Psetidomonas Aeruginosa) in a capillary glass ttibe connected to tbe apex of root filled extracted litiman teetb as an indicator of leakage and found most obttti ated root canals do not allow the ]3assage of tbis bacterittm. Because of inherent inadequacies in dye and radioisoto]3e leakage stttdies, and a lack of correlation between bacterial leakage and those of dye
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and isotope molecules, bacterial leakage studies bave been tecomtnended to test the stiitability of potential root-end filling materials (8587). Kos et al. (85) e\ahiated the ability of polyHEMA as a toot-end ftllitig material and fonnd tbat tbis material prevetited leakage oi Proteus rnilgaris, at! actively mc:)tile gram negative rod and Strt'ptoeoceus stdivurius, a gram positive coccns normally foittid itl tbe liuman oral niictoflora. In conttast, ccjld-btittiisbed gtitta-petcba, beat-sealed gutta-percba, and zinc-free amalgam sbowed a bigb incidence of leakage ranging from 80% to 100% of tbe specimens tested. Euomanen Sc Ttiompo (86) compared tbe tightness of fitanium screws versus amalgam as roc3t-etid filling tnatet ials, using Sermtia inarceseeiis in an in vitro model. They found that die bacteria penetrated around tbe apical fitanitim screws in 2-7 days, and atotind tbe t ettograde amalgam fillings on tbe first day of the expetitnent. Stainitig of tbe teetb witb Itidia ink sbowed tbat penetration of bactetia bad occut red at the tooth/filling mat gin. Wotig et al. (87) compared tbe apical seals obtained by placing either amalgam as a t oot-etid filling material ov lasing the root apices witb tbe NchYACi Easet\ After instrtimentation and obttnation, otie group received amalgam as tocn-end filling material and eigbt other groups wete lased witb tbe Nd:YAG Easer at wattages tatiging fVom 0.75 W to 3.0 W for 20 s. Streptocoerus snIixKiriu.s was placed in the cc:)iotial tesetvoitof each toot atid its apical 10 mm was placed in brain-beart inftision btotb and pbetiol red indicator. Their restilts sbowed no significant difference between bactetial leakage in the laser-treated gtoups and tbe samples tettofilled witb amalgam. (4:)mpared witb clinical conditiotis, tnoclels used in bactetial leakage stttdies to determine sealing ability of variotis toot-end fillitig materials bave several shortcomings. Tbey are static and tbeir bacterial contents are dissimilar to those found in human saliva. In addition, these sttidies did not determine the ability of toot-end filling materials to ptevent leakage of bacterial metabolites and tbeir by-ptochtcts. In vitro txnd in rv'r'(^> animal mc^dels simulating clinical conditions are needed to obtain quantitative data and detetmitie tbe relationship between leakage of bacteria and their byproducts and pet iradicular iiiflainmatic:)n. li. Marginal adaptation Tbe scanning election microscope (SEM) bas beeti used in dental tesearcb to sttidy normal and itifiamed gitigival tissues. (88), plaque structure (89), caties fortnation (90), tbe effects of etching on niarginal adaptatic:)ti of vatious restorative materials (91) and tbe interface between tootb structure and testorative tnaterials sucb as gold, composite atid atnalgatn (92). Itl scantiitig electton mictoscopy. specimens are considered as a collection of point sources of tadiatic:)ti, eacb of wbich ttansinits information concertiing" composition and sttiu tine. The SEM uses a 2-3 nm spot of electrons tbat scans tbe surface of tbe specimen to getietate secotidaty electic:)tis fiotn the specimen which are tbeti detected by a sensot; Tbe sensor uses tbis emitted ladiatioti tc:) build up a picture of tbe complete object. In effect, oiitpnt signals fiom tbe SEM are reflected fiom at! ojDaqne stit face. Geomettically, tbe reflectioti of electrotis fiom the SEM specitneti surface obeys tbe same laws as tbe reflecticin of light from an irregular surface. The result is tbat SEM images ate fbrtned in topogtapbic conttast - tbe image intensities ate related to vatiations in surface topograpliy. Tbe images appear like tbose viewed tiiactoscopically ot; iti otber wotds, tlnee ditnensional. In general, electron mictograpbs represent an overlav' in wbicb details fiotn tiiatiy levels of tbe specimen appear, in focus, witbin a sitigie plane (93). In endcidotitics, a tiumber of investigatots bave utilized SEM to investigate tbe marginal adaptatioti c:)f tocn-etid filhng materials (28, 9499). By using SEM and teplication tecbnique, Cunningbam (94) comparecl tbe apical appeatance of eigbt teetb obturated witb silver cones and sealet; gutta-percba and sealer with and without rocî-end resection, and atnalgatn as toot-end filling material. Considerable disinpdon of tbe apical seal was seen in tbe roots apicected after gutta-petclia obtutatic:)n. Tbe stnc:)otbest sut face and best seal appeared to bave been acbieved b) toot fillitig vsitli a silver poitit befbte apical resection. Rettc:)grade amalgatn fillings appeared satisfactory, btit giittapetcba points used befbre and specially after tbe reduction of tbe apex appeared to bave titideigone considetable clisttiption. Moodnik et al. (95), fbnnd defects of 6-150 |um around amalgam tettofillings using tbe SEM. These deficiencies atound amalgam retrofillitigs questic:)ned tbe validity of ibis widely accepted tecbnique. However, tbe authors did not elaborate on tbe clinical significant of tbeir findings. Tanzilli et al. (100), cotnpated tbe tiiargitial adaptatioti, using tbe SEM, of retrogtade amalgam, beatsealed gtitta-petcba, cold-burnished gutta-petcha, and apicoectomy only. Tbey concluded cold4)utnisbed gutta-percha was "90% better tban ativ of tbe otber tecbniqnes investigated." Retrograde amalgatn, heat-sealed gutta-percba, and tbe apic-
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oectomy control showed mean marginal defects from 22 \xm to 10 |J,m, while cold-btunished guttapercha exhibited a mean defect of only 1.8 jim. Alxlal & Retief (28) used SEM to compare the marginal adaptation obtained by jDost-resection filling with heat-sealed gutta-percha and when reinforced with 16 retrofilling materials (one sample per material). Most materials tested had gaps. However, no gajos were found in Cavit, Sybraloy (high-copper), polycaiboxylate cement, gkiss ionomer cement, heat-sealed gutta-percha, and Adaptic. In an SEM study, Stahholz el al. (9(3), compared the marginal adaptation of root-end filling with Restodent, zinc phosphate cement, Cavit-W, Dtuelon, and amalgam. Restodent sealed significantly better than the other fotir materials and demonstrated the best adaptation lo cavit)' walls, while amalgam was significantly inieiior to the four other mateiials in both marginal adaptation and seal. In addilion, they showed zinc phosphate did not differ signillcanlly from Cavit or Durelon. Yoshinuua el al. (97), in a coronal and apical microleakage study using a pressurized fluid filtration technique and SEM examination of teeth with retrograde amalgam fillings, showed leakage decreased markedly in the 90 minute to six hour interval after filling. Small changes in leakage were noted belween 1 clay and 8 weeks. Leakage from the coronal direction was not significantly more than that noted from the apical direclion. Gaps as wide as 20 |im were noticed between amalgam and the toolh structure in some selected specimens. They found no correlation between microleakage and the width of the gap appearing on the sttrface. Inoiie et al. (98) compared the microleakage of amalgam, amalgam with a cavity \'arnisli, a silvetcontaining glass ionomer (Miiacle Mix) and IRM using a lltiid filtration t:echniqiie and SEM observations. Cilass ionomer cement and IRM showed siguificantly less microleakage compared with the amalgam group without varnish. The use of cavity vaitiish reclticfd the apical leakage of amalgam significantly. Examitiation of scanning clectroti photomicrograplis of some selectied spccinu-tis sliowed tlie presence of gaps ranging 5-10 fJni between the root-end materials and tlieir surrounding denlinal walls. Toial)inejad et al. (99) in a clyc leakage and SEM examination of four retrogtade amalgam root-end fillings from lbttr radiogiaphically successful lcc[h showed presence of nietliylcne hlite dye pencti alien through the interlace of amalgam and rool-end cavities and varying size gaps l)etween the cavity walls and amalgam. These invesligatots qttcstioned the cortelation lietween d)'e leakage, SEM studies and clinical succe.ss. Specimen piepaialion (or examination with the SEM involves several steps, each capable of inducing artificial changes in the specimen. These steps include: fixation, dehydration, drying, hea\')' metal sputter-coating, and high-prcsstirc vacutuiiing which can result in the fortnalion of artifacts. To prevent or icdttce the amcnuit of ai tilacts, different methods have been proposed to ]jr()dticc teplicas ol the original samples. Invesligatots have described replication techniques to study ihe toolh structure-filling material interfaces, and die miciovasciilaUue of ihe pulp (101-103). Moodnik et al. (95), and Torabinejad et al. (99) in their case reports revealed the presence of large defects at the amalgani-loodi interface, 'fhese studies wiih dieh' small sample sizes as well as the study by Tanzclli et al. (100) did not utilize any replication technique lo minimize the introduction of artifacts. Al:)dal & Relief (28) employed a negative/positive replication techtiiqtie to e\altiale only a single sain]3le of each ofthe Hi root-end filling materials. However, in this study, ihe teetli were sectioned longitudinally with a diamond saw, which may have alfecled ihe findings. Stahholz et al. (9(T) used a negative replica technique and sectioned their samples which might ha\e affecled the results of this invesligalion. Yoshinuua et al. (97) and Inoue et al. (98) also reported presence ol gaps between root-end ca\'ity walls and amalgam in some selected cases in iheir leakage and SEM investigations. Despite its shortcomings (introduction of artifacls during sample preparalien, showing only 1 stnface which may not represfnt adaptation of 2 surfaces in ?> dimensions and a lack of tort elation lêtween maighial adaptation and sealahility). SEM examination of mat ginal adaptation of various root-end filling materials to iheir surrounding strtictitres cati ]3nn'ide itifoiiiiation which could he used as an iiiflit ator of the scaling ability of these materials.
ilL Biocompatibility The materials tiscd in endodontics are Ireqtientfy placed in intimate contact wiih ihc liard and soil tissues of the pcriodontittm. This is partictilarl)' true for the substances ttscd as root-end lilling materials. Therefore, it is essential that a potential root-end filling material be non-toxic and hiocompatihlc with its sttrrottncfing host tissues. CAUtently, there are three recomniended tests lo evaluate biocompatiljility of dental materiafs. An initial test which provides general loxicity profile
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of potetitial materials, secotidary tests, wliicb e\aluate local toxicity, and usage tests iti wliicli the potential sitbstances are used in tbe teetli of experitiiental animals accorclitig to clitiical prc:)tocols. A. Cytotoxicity tests Cytotoxicity is one of tbe most connnonly tised in vitro tests to tneasure biocompatibility. It is a simple, rapid, and inexpensive screening test, aticl gives a valuable iticlication as to which materials should be discarded or subjected to further testing. Many methods have beeti used to determine tbe cytotoxicity of variotis dental tnaterials. Tbese methods itivolve either observitig the inbibition of cell growth or recorclitig cellular injuty ancl/or deatb. Tbe tliree most commonly used cytotoxicity tests include agar overlay tecbtiique, millipore filter tiietbod and radiochromium release test. 1. Agar overlay technique In this test the cells are first cultivated to a confluent monolayer in 24 bours. After removal of the culture mediutii, tbe cells are covered witb Fagle's Minimum Essetitial Medium (MEM) supplemented witb 1% calf sertun and 1% agar and stained witb 0.01% Neutral Reel solution. Tbe test material is tlien placed oti tbe agar sitrlace and incubated for 24 hours. Tbe cell monolayers are then examined utider an inverted microscope and the plates are vistiallv atialyzed for celltilar lysis. Tlie dead cells lose their Neutral Red staining atid will provide a clear zone subjacent to the test material. The toxicity of the niaterial can then he registered according to a lysis index from 0 to 5 (104). degree ol toxicity ofthe material can be registered from 0 to 3 indicadng the extent of the zone with redticed or inhibited enzyme acti\'ity (fO.'i). 3. Radiochromium release test According to Spangberg (106) the radiochromium release test is the third commonly used method to asses cytotoxicit} of \aiioits dental materials. In this tnethod, the test tnaterial is first jDlaced in the bottom of the wells of tissue cnltiue plates. It is then covered and itiocnlated with grown, harvested atid prelabelled cells with Na'^'CrO, for 1-24 hours depetiding on the experimental design. After appropriate incubatioti period, a standardized amount (1.0 niL) of the citltttre niecliitni is withdrawn from each well and the amount of ''C'-r released into the medium is measiuecl iu a ganinia particle countei. A comparison between the amount of the original incorporated radio-clironiiinn in the cells wth that released from cells after incubation with the test material as well as the positive and negative controls is used as ati iuclicator of toxicity of a dental material (106). The cytotoxicity of potential root-etid lillitig materials have beeti determined by several investigators using various techniques (107-117). Spangberg et al. (107), used radiochrotnium-labelled HeLa cells to test the biological effects of some potential root-end filling materials and reported that freshly prepared 11^4 proditced total cell lysis, while after setting for 1-4 weeks the toxicity decreased slightly. Iti addifion, they showed relati\ely low cytotoxicity of polycarboxylates as compared with ZOE atid IRM. Dahl & Tronstad (108) deteiininecl the cytotox icity of a glass ionomer (ASPA III) cetnent and a cotiventioual silicate cement using the racHo-chrotiiiuni tnethod. Based on their findings, it appeared that the silicate cement was less toxic than the glass ionomer cement and the toxicity of the latter decreased with setting time. Antrim (109) used radioacti\e Cr released from KB carcinotiia cells as a measnre of cell lysis in response to Groosinan's sealer, N2 (permanent), Rickert's sealer, and Ca\ it. He reported that all the materials tested possessed lastitig tisstie toxicity; Cirossman's sealer was the most toxic material, followed h\' N2, Rickert's, and Cdvh. Cavit showed a low initial toxicity (24 hoius), bitt this increased with titiie and remained highly toxic theteafter. The response to C.a\it was somewhat erratic and was attrihttted to the deterioration of the tnaterial. Tronstad & \A'ennberg (110) compared the toxicity ol" dental amalgam.s, silicate cement, methyl
2. Millipore filter method Wennherg et al. (10.5) introchtced the "Millipore filter method" iti which Millipore filter disks are placed in tissue cultiue disks and covered with cell suspensions cotitaitiing hutiiati epithelial cells, HeLa cells or mouse fibroblasts (L929). Alter establishmetit of a cell monolayer on the filters and removal of culture mecliitni, the filters are covered with Fagle's MEM and 1.5% agar. The nutrient agar is allowed to stiliclily and then the agar filter is placed in the Petri dish ttpside down. The test material is placed oti the filters atul allowed to infiuence the cells foi 2-24 hours. The stainitig ititen.sity of monolayer cells for sticcitiate dehyclrogenase activity is used as the indicator o.f cell vitality around the test materials. The relative
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Torabinejad & Pitt Ford metliactylate resin, composite resitis, zitic phosphate cement, polycarboxylate cement, ZOE paste and caiciutn hydroxide GR-isotonic paste on mouse libtoblasts by means of Millipore tecbnique. Tbe convetitional amalgams and a bigb copper atnalgatn (Dispersalloy) sbowed sitiiilar responses. Tbe ccjiivetitional atnalgam atid bigb copper amalgam were initially sotiiewliat toxic witb a decrease in toxicity after 24 bouts. Hc:)wevet; tbe old style bigb copper alloys (30% copper) were more toxic. Zinc phosphate atid silicate cemetits as well as methyl methacrylate resin were highly toxic when fieslily mixed. T h e wet and dry varieties o[ ZOE paste were moderately tcjxic and calcium hydroxide paste proved to have a sttong and lasfing toxic effect. Wennbetg & Hasselgreti (111) evaluated tbe cytotoxicity of a number of temporary filling materials including Cavit, IRM, atid ZOE cement by tbe Millii:)ore filter tnetbod and sbowed tbat all tbe cements had some degree of cytotoxicity tlnottgh the experimetital petiod; ZOE atid IRM showed a cotititiuitig decrease iti their cytotoxicity with time. Meiyon et al. (112) compared the cytc:)toxicity of two glass ionomer cements (ASPA and ChetnBond) on fibroblasts and tnacropbages. BcDtli tnaterials wete fbund to be itiitially cytotoxic to fibroblasts; tbis was evidetit by tbe itibibition of sticcinic debydtc:)genase stainitig iti cells grown on Millipore ftltets. These sttbstatices were also cytotoxic to macro|3bages assessed by a teduction iti cell ntimbets and by enzyme staining kinetics atid quantitative enzyme atialysis. T b e cytotc:)xicity of botb tnatetials decreased considetably after 24 bours. Milleding et al. (113), cotnpared tbe telative cytotoxic effect of corroded and non-cot roded amalgams of different types using a cell culture and Millipore filter metliod. C/ortosioti was produced by storing the anialgatn in distilled water or attilicial saliva with a pFI of 4, 5, or 7 for up to 28 weeks. Tbe set, non-corrc:)ded amalgam did not show any cytotoxic effects, whereas corroded amalgam sutfaces showed various degress of cytotoxicity. Al-Nazhan et al. (114), compared the cytotoxicity of a composite resin (Restodent) with tbose of Cavit and Dispersallc:)y using the radiocbromium labelling tecbtiique. Tbeir results showed tbat Restcjdent was mc:)re toxic tban atnalgam; Cavit bad no toxic effect. They concluded that amalgam was sdll tbe material of choice due to its lc:)w cytotoxicity, and that composite was tbe most toxic tnaterial tested and should not be used. Safavi et a l (115), attetnpted to gtow fibtoblasts oti root-ends filled witb amalgam c:)r compcjsite tesiti. Study of tbe cell attacbment to tbe sttbsttate uticler SF^M sbowed cell attacbtneut to tbe cotnposite surface was tematkably less tbati tbat to amalgatn. Pissiotis et al. (116), conipated tbe cvtotoxicity of silver glass iotiomer (SGI) cetnent atid atnalgam ttsing '''Cr telease test and foutid tbat SCil pltis varnisb was less cytotoxic tban amalgam. Tbey cotichided that SGI sbould be cotisidered as an alternative rocjt-end filling material. Brtice et al. (117) measured the cytotoxicity of sevetal dentitie botiding systems, SttpetEBA atid amalgam using tbe agar overlay test at 24 bouts, 7, 15, and 30 days. Except for amalgam aticl Ten tit e Visar Seal, the test of the materials wete itiitially cytotoxic. SupetEBA, Cattlk-filled tesin, and Gliima sealer & Glitma bond were itiitially toxic and tbey lost tbeir toxicity 7 days after incubatioti with the monkey kidney cells (Vl^RO). (Xtotoxicity of atnalgam inct eased as it aged. Based on their results tbey concluded that sotne detititie bonding agents are cytotoxic; bovvevet, they lose tbeir cytotoxicity as tbey age. Based on tbe results of tbese sttidies it appears tbat ZOE-based tnaterials iti tbe fi esbly tnixed and unset state ate vet"y cytotoxic atid tliev' lose their cytotoxic effect as tbey age (107, 109, 111-117). Confiictitig teports bave been made regarding cytotoxicity of Cavit, glass iotiomer cements and composites. Despite tbe ease cjf conttol of experitnetital factots iti cytotoxicity tests tbere ate sevetal disadvantages with perfbttnitig these yirocecltires. T b e resttlts of tbese tests at e relative, cannot be cc:)mpared with one atiotber, atid are clependent on cell types atid degree of dilTusibility of test matetials. Iu addifion, these invesfigations cannot study the complex interaction between matetial and bost tissue and tbe measurements obtained by tbetnselves bave little relevance to clitiical citctunstances (106).
B. Implantation tests
Because of limitation of cytotoxicity tests, in vix'o stibcutaneous and itittaosseous itnplatitafion teclinicjues in small laboratc:)ry anitnals bave beeti tecotnmended (107, 118-121). Subcutaneous and intraossecius implantation tecbniqnes are consideted stiitable secotidaiy tests to evaluate the biocompatibility o{' variotis dental materials. Early implantation sttidies involved placemetit of pellets o[ dental materials in vatious soft tissues aud bones. The iinjilantatioti metbod was refined when Friend and Browne (118) used Tefion ttibes as a vehicle to place small staudat clized surfaces of fresh or set dental materials in contact witb desig-
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nated tissties. Accotclitig to Spangbeig (106) tbese tests can provide valuable information witbotit excessive cost and unnecessary animal sacrifice. Potential root-end filling materials bave been implanted stibctitaneotisly and intraossecnislv in small labotatory anitnals (122-133). Wolfsoti & Seltzer (122) used an injection tecbnique atid implanted sevetal brands of gitttapetcba, natural gutta-percba, latex, ati expetiniental formtiladon containing gtitta percha (20%) and calcitmi bydroxide (80%), and Kloioperka N-'O in tbe subcutaneous tissue of tats. Histological examination of specimens sbowed an initial acute response followed by fibrotis tissue encapsulation. Kloioperka N-"O caused severe tissue destruction and infiaminatoty cellular infiltrate cotitaining PMN leukocytes, mactophages, lymphocytes, plasma cells and giants cells. The gutta-percba formulation with calcium hydroxide elicited a fbt eignbody giant cell response. Flanders et al. (123) itnplanted zinc-fiee atnalgam atid Cavit stibctitaneonsly and next to the bone itl rats and evaluated tbem liistologicallv' after 10, 30, 90 and 180 days. Cavit produced more of a foreign body reaction than amalgam in both tissues. Cavit ptodnced osteocvtic deatb in tbe adjacent botie and a tbicker fibrotis capsule next to connective tissue. The iuflaimnatory response to botb tnatet ials decreased witb titne. In a bone implantation study, Zartner, et al. (124) placed ficsbly mixed amalgam and zinc polycarboxylate (ZPC) cement into tbe tibias of tabbits atid evaltiated tbem bistologically at 2 weeks, 2 and 4 montlis. ('ompatison of tbe bone adjacent to ZPC cement atid amalgam sbowed identical fissue respotises. Tbete was evidence of viable osteocytes, liealtby vascular and connective tissue, aud a lack of iuflammafion. Martiti et al. (125), evalnaied tbe tal cotinective tissue response to zinc containing amalgam, zincfiee amalgam, and zinc catbonate crystals atid evaluated tbem bistologically at 2, 14 and 30 days. Tbere was tic:) significant difference in inflatimiatory respotises to zinc contaitiing or zinc-free amalgams at atiy time ititetval. Iti conttast. zinc catbotvate showed a severe ibreigti body giant cell and maciophage response. No zinc carbonate was foi med in any of tbe zJnc containing s])ecitnens. However, tbe specimens were nc:)t placed in coulact witb another metal to allow for the electrolysis required for zinc catbonate lormatioti. Liggett et al. (12f)) placed fVesbly mixed zitic aud liou-zinc amalgam in ibe tibias of rats and exatnined them via light mictoscojiy, SEM, and tiiicro]>robe analysis. Over a period of 12 weeks tbey found botli types of atnalgatn to be well tolet ated bv' tbe rat c:)sseous tissue. Hovvevet\ tbe inicroprobe analysis showed evidence of tin and sulpbiir in tbe bone adjacent to tbe implants witb bc:)tb amalgam types. Tbey attributed this to the formation of corrosion prodticts aud breakdown of the alloy. Ztnener & Domingtiez (127) compared tbe biocompatibility of zinc ]Dliospbate cetnent witb a glass ionomer cement b\ itnplantaticMi in clog tibias. Initially, tbe glass ioiK:)iner cement caused less infiammatorv response than the zinc phosphate. Hovvevet, at tbe end of 90 days tbe tissue response to both tested materials appeared to be similar, with resoliitioti of inflammation and progtessive tievv bone formation. Based on tbeir findings, tbe autbors tecommended tbat glass ionomer sbould be considered as a re]Dlaceinent for tbe zinc pbospliate cetnent as a luting material. Blackmail et al. (128) placed freshly mixed pellets of glass iouomer-silver cement lightly cc:)ated witb a cavity vartiisb and IRM into tbe connective tissties and bones of rats and exatnitied them histologically after 14, 30 and 80 days. Despite pt esence of mild inflammation UJD to 80 days, each material ap]Deaied to be well tolerated. Bone apposition occntred acijacent to glass ionomet-silver, while fibrosis was observed next to IRM. Eeonardo et al. (129) studied histologically the subcutaneous connective fissiie responses of rats to tbe placement of tbree different formulations of gutta-percba: Obtura, Ultrafil, and gutta-percba pc:)iuts tecotntnended for use witb tbe McSpadden compactor svstem. Obtiira giitta-percba showed a severe inflammatory response fiom the 7tli to tbe 120tb dav similar to that seen witb gtitta-percba recommended for tbe McSpaddeu technique. The Ultrafil gtitia percha caused a severe response initially wbicb became modetate and mild in subsequent observation periods. At 21-, 60-, and 120day intervals, tbe Ulttafil giuta-petcba was assc:>ciated witb mature grannlatioti tissue with neitber c:)edema nor vaseular cc^ngestiou, iu contiast to the responses observed with the other twc:) formulations. Mcaiee & Ellender (130) compared tbe biocompatibility of SnperEBA and Ketac-silver glass ionomei; ati atnalgatn, a ZOE cetnent atid silvetfree /VH26 by sufxutauecnis implaiUatiou of ibese tnaterials iti rats. Initially, ZOE, amalgam, and SuperEBA were associated witb moderate inflammation. By 100 days, tbe latter tnatetials and Ketac-silver glass ionomer were encapsulated witb fif^rous cotmective tissue. Howevei; .'VH26 was associated witb necrosis and persistent inflatnmatic:)n and gtatiiilatioti tissue formation. To test tbe disinfection effect of parafbrmaldebyde on gutta-petclia, Ckniry et al. (131), com-
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pated tbe bistological tespotise of a 7-clay exposure of parafbrmaldeliyde treated gutta-percba witb untteated gtttta-petcba (Obtiita) implatited in lat cotinective tisstte. Tbe untreated gtittaperclia sbowed moderate to sevete inllatiimation for 4 7 days, wbicb decreased progressively. At 56 days tmtreated gutta-percba was associated witb mild to no infiammatioti witb fibrous capsule formation. Tbe parafbt tnaldebyde treated gtittapercba sbowed significantly less inflatnination in the early stages (4-7 days) of implantation. The tissue responses to botb treated and untteated gutta-percha were very similar at the end of tbe experiment (56 days). Tbe samples were associated with capsule Ibtmatioti and presetice of tnacrophages and giant cells. Bliambliani & Bolanos (132) implanted Teflon, IRM, and Ptisma VEC Dycal in tbe tnandible of guinea pigs for 4 and 12 weeks. Tbeir bistological findings indicated apposition of botie adjacetit to the Prisma Vl.C Dycal: none io mild itifiatiimation and a thin fibtous connective capsule near IRM, and a tbick capsule acijacent to well condensed Tefion |iowder tnatetial. Eoosely condensed Tefloti mateiial caused cbronic itinamtnatioti ancl active pbagocytosis. To evaluate the ossec:)tis teaction to IRM, Opotow Alumina EBA, atid atnalgatn, Olsen et al. (133) implanted these siibstauces iu tat tibias and examitiecl tbem liistc:)lc)gically fiom 7-100 clays. Complete healing occiitred arotmcl Teflon cups containing IRM or amalgam wbile EBA specimens had mote innammation at 56 days. At 100 days, healing also progressed to completion adjacent to EBA cement grotip with only ati itifreqtietit pte,sence of leukocytes. Based on their i esults, tbe authors stated that botb IRM atid EBA cement wete acceptable biological altetnatives to amalgam. The results of implantatioti studies show that most potential toot-end filling materials initially cause itifiammatioii and tbey become more biocompatible as Ibey age (122, 1 30, 131,133). Tbis is partly as a tesitlt of sttrgical ttatttna atid also release of leacliable substances fiom tbese tnatetials. In additic:)n these studies sbow that iniplatited gutta-|K-tcba is usually encapsulated witb fibrous connective tissue (122, 129) and (bete are no hi,stolf)gi<al differences between tbe tissue re,spc:)iises to zinc-conlaining and zinc-fiee amalgams (125, 126). Fill tbermore, IRM, EBA, and glass ionomer cemetits are well tolerated by cotmective tissue as well as bone (127, 128, 130, 1,32, 133). Becatise of possible diffetetices in tissue responses ill different animal species and locations, vatious tnethods of evaltiation atid shot f observation periods, the tesults of various implantation sttidies catitiot be cotn|3ated. hi subcittatieous implantation, tnechanical displacement of implanted tnatet ial has been recognized atid is tioted as a disadvantage of tbis techtiique (134). Tbis deficiency cati cattse ati itiability to acbieve jiroper matetialtissite contact. Despite advatitages, ati artificial botiy cavity and its content (Teflon cup & test tnaterial) used in intraosseous implatitation are diffetent from a toolli suspeuded iu tbe periodotital ligament. As stated by Olsson et al. (135), botb itnplantation tecbniques can provide important infotniation tegarding tbe cellular t espotise to deutal materials. Howevet\ tbe autbors state tbat it is difficult to make tbe asstimpfion tbese tests ate cotiipatable to usage tests. Tbe results of tbese tnetliods like those obtaitied iti in vitro tests should not be used as absolute values and can be only itsed as indicatots ol biocompatability of test matetials. IV. Usage tests As discussed earlier (Section III-B), implantafion metliods have several shortcomings compared to nsage tests. Despite dieir costs atid lack of complete standatclization of clinical variables, tbe usage tests cati ]jtovide infc:)rmation related to biological projDerties as well as bandling cbaracteristics of test materials under clinical cit cumstances. Tbe usage tests ate performed iu expetitnental animals and clinical trials iti man. A. Periradicular tissue responses to root-end filling materials To examine tbe petiradicular tissue tesponses to potential root-end filling tnaterials, tbe root canals of experimental animals ate usually cleaued, shaped, obturated, and after loot-eud tesection atid ptepatation of root-etid cavities, tbey are filled with test materials. The animals at e then sacrificed aud their petiradicular tissues ate examined bistologically to determine the biocompatibility of test tnatetials at diffetetit time intervals. A number of bistological evaltiations of periradicular tissue reponses of monkeys, dogs ancl ferret to some of the commonly tised and potential tooteud filling matetials bave been reported (77, 78, Marcotte et al. (136) compared tbe periradicular tisstie responses of the pettnanent anterior teetb of two tbesus monkeys to gutta-percba (following apicoectomy) and zinc-free amalgam. Alter performing root canal fillings ancl apicoectoinies oti 12 antetior teeth, tbey filled six toot-end cavities witb amalgam. Tbeir bistological evalitatioii of
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two specinietis jier time ititetval at 3-15 weeks sbowed bealing of siitgical defects regardless of wbicb of tbe two ioc3t-end filling materials bad been used. Starting at 5 weeks, collagenotis fibrous cc:)nnective tisstie coveied gutta-percba and amalgam. Maturation of ibis tisstie atid formation of bone wete observed at subsecjuetit time intervals. New cemetitntn covered tesected toot-etids startitig at tbe 7 week interval. Kimura (77) evaluated the petit adicular fi,s,stte reactioti of four dog teeth t etrolilled witb zinc- or zinc-ftee alloys. Histological exaniinatioti of four specitneiis at various time intervals (1-22 inontbs) sbowed presence of some inllamination in the 1and 7-inotUb sjiecimeiis ancl severe itiflammation adjacent to botb materials after 12 ancl 22 moiitbs. In tbe second patt of bis study, Kitnuta (78) determined tbe concentration of eletiients by c:)ptical emission spectrograpbic analysis in eigbt specimens at eacb time interval (1-22 montlis) and fbuucl no zinc precipitate iu jieriaiDical bone adjacent to toc:)t-etids ftlled witb zitic-cotitaiiiing or zinc-free alloys. Callis & Santini (137) cotnpated tbe periapical tissue t espouse of 10 let rets lo gutta-percba and glass iotiotner cement wben used as root-end filling matetials fbr 7 and 28 days. Botb materials caused otily a mild infiammatory tesjiotise after 7 days. At 28 da) s tbe glass ionomei- samjiles sbowed more bone formation and no inflammation. The gutta-percha specimens bad good liealiug wiib tnild infiainmation. Tbe sealer (Tnbiseal) used with the gutta-percba migbt bave contribtited to tbe presence of inflammation. Iti conttast to the presence of a layer of fibrous connective tissue separating gtttta-percha from bone, botie formed in direct contact witb tbe glass ionomer cement (Ketacfil) used. Mangkornkatn & Harrison (138) evaluated amalgam and thettnoplasticized gtttta-petcha as rc:)Ot-eiid filling materials in six monkeys at tbree titne intervals (4-16 weeks). Tbeir bistological findings indicated slower bone bealing associated with tbermo-plasticized gutta-percba than amalgam at 4 and 8 weeks and no significant difiet etice in tbe o,sseoiis healing at 16 weeks. Both matetials ap|:>eaiecl to be well tolerated and biocompatible to the periapical tissties. Zetteicjvist et al. (139) compared tlie periradicular fi,ssue responses to glass ionomer and atnalgam in eigbt monkeys afler 2 weeks, I, 3, aud 6 motitbs. At 2 weeks, itiliamtnatoty cells wete ol> setved close to tbe loot-encf filling materials. One month after siitgety, (be granttlation tisstie had started to be replaced by new bone. Alter 3 and 6 tiiontbs, cotnplete healing was noted adjacetK to botb rooi-etid ftlling materials. Based on tbeir tesnlts, tbe aiitbors recommended glass ionomer cement to be considered as an alternative to amalgam fOr patients suffering from alletgic or toxic 1 eactious to mercury present in amalgam. Pitt Eotd & Roberts (140) examined the per: iradicular tissue t espouse of eigbt centt al incisors in fbtir Cyiic:)inolgus monkeys to a tadiopaqtie glass ionomer cement with and v\itlioiit root canal filling materials. Contaminated canals witb apical glass ionomer as a root-etid filling mateiial but witbont a root canal filling bad severe infiainmation and abscess fbrniation adjacent to root-etid filling matetial. However, teeth with glass ionomer root-eud fillings ancl gutta-percha root canal fillings were associated witb either no infiainmation or a mild response. Bacteria were fonnd in tbe interface of glass ionomer and dentine in every tootb witbotit a root canal filling and bad extended apical to tbe root-end filling matet ial. Rud et al. (141) examined tbe periradicttlar tissue tesponse of two green Veivet inonkevs to a cotnposite resin (Retroplast) as a root-end filling matetial. After filling toot canals of two maxillary inciscM s and canines and placing Retroplast at their tesected root-ends, tbe tissues were examined histologicallv' 1 year following surgerv\ In some" casc\s epithelium and inflammatory cells were seen in periapical tissues. In c:)iher eases, there was an absence of inflammatorv cells adjacent to tbe filling material, but close contact between the Retroplast ancl fibroblasts with collagen iibies. In one case, cementum and Shaipey's fibres were Ibuud in contact widi tbe filling material. Pitt Ford et al. (142), examined tbe effxxl of IRM and amalgam as root-eud fillitig materials ptior to replantation in 42 roc:)ts c:)f mandibular molars of monkeys. Following extraction and contamination of canals witb tbe mc:)nkey"s oral flora and placement of IRM or atnalgatn as root-end filling materials, tbe teelli were teplanted and the ti.ssttes examined after 8 weeks. Tbe tissue tespouse t T IRM was less sevete tban tbat to amalgam. Sixty c percent of roots filled with IRM were associated witb inflatnination. In contrast, 92%. of roots filled with amalgam bad petiapical itillatntnation. No root with IRM as tbe root-end filling material bad innanimation iti (be bone tnattow space. In conttast, iuflanimation was present in the alveolar bone mat tow space witb every root-end filled with amalgam. Using a similar surgical tecbnique. Pill Fold el al. (14,3) itivestigated the periradicular tissue response lo root-end fillings of SujieiEBA in eight toots of tnotikevs and tepotted a tnild inllammalory response. ExcejM for one sttidy Pitt Fotd et al. (14,3), the
171

sample size in usage tests in experimental animals fc:)r eacb time intet val seems very small (24 samples). Tbe observadon periods in most of tbese studies ate relafively sbort and may or may not represent clitiical citcmnstances. Except for four studies (77, 78, 140, 142), wbicb contaminated die root canals of teetb put posely, tbe rest of these sttidies filled tbe canals witb root-end filling materials under ideal citctimstances. Mcjst of tbese studies used subjective ctiteria for tbeir bistologic assessment. Becatise of limited sample numbets no statistical tests wete used to analyze tbeir findings. B. Clinical usage Sealing ability, marginal adaptatioti, in vitro cytotoxicity tests, itnplantation atid usage tests in experimental animals are screening means to eliminate materials with unacceptable degrees of leakage ancl bigb levels of toxicity. Tbese tests are prerequisite exercises and are not stibstitutes fbr clinical studies. C^llinical comparison of potential roc3t-end filling materials under similar c:)petative and postoperative ccjnclitions is the ultimate and tbe most reliable metbod for evaltiation of tbeir clinical usefulness and tbeir long-term efficiency. Clitiical investigations ate perlbtmecl iti retrospective or prospective manners. A mitnber of clinical stttdies bave been reported on vat ious toot-end filling materials (144-162). Harty et al. (144) iti a tettospective study examined tbe success rate of apicoectomy in 1,016 cases at 6 and 12 months and yearly thereafter at least for 2 years and reported no significant diffetence between using amalgam as a root-end filling material and nonsurgical root canal therapy using gutta-pet clia or silver points in cotijunction with a ZOE sealei. They reported teeth with preoperative radiolucencies had mote failures than tbose withoul them. Rtid et al. (145) exatnined tbe coutse of bealing of 1000 teetb tteated by surgical endodontics and reported tbat most completely healed or tmsuccessfully bealed cases had nc:) significant cbatiges (were stable) irrespective of the observatioti period. Bee ause significant cfianges were noted in incotiipletely healed cases within the first few years following periapical .svirgery, they recommended a final 4-year fbllow-tip observation period in cases sbowing uncertain bealing. Rud et al. (146) perfbttned a nitikivariate analysis ofthe satiie siiigical cases wbicb had been followed fiom 1 to 15 years after opetation. Their results showed tbat cases witb gutta-percha toot fillings had significantly less infiainmation than tbose rettofilled; retreated cases bad more petiapical itiflammafion dian teetb without previous root canal filling; tnediutn sized bone cavities bad more periapical infianmiation; maxillary lateral incisors wete iiior fieqtiently associated witb scar fbrmafion tban maxillary canines ancl premolars; perforation of lingual cortical bone was associated with a later occurrence of scar tisstie; scar tisstte was fbtind more often after opetation on cysts; atid tbe age group from 20-40 years often sbowed scar tissue at final follow-up times. Ill a radiogtapbic atid clitiical examination of 93 apicoectomized roots over a period ol 1-6 years, Altoneti & Mattila (147) found over 80% witb complete bealing, 6% uncertain bealing, and 13% ccjtnplete failure. No differeuce iti bealing was tioted betweeti cases with cysts comparecl with tbose witb granulomas. Tbeir findings also indicated tbat placement of a toot-end filling material itnproved tbe success rate of existing ottbogtacle filling materials. In addition, tbey found tbat die presence of multiple periapical lesions advetsely affected tbe prognosis of teetb requiriug surgical eudodonfic tlietapy and removal of one balf of tbe toot led to mot e complete healing (89%) tban lemoval of apical '/) cif the roots. Finne et al. (148) condticted a 3-year postoperafive clinical evaluafion of padents wbo bad Cavit (102 cases) and amalgam (116 cases) as root-end filling matet ials, atid coticluded that atnalgam was sigtiificantly better tban Cavit. They made the statement that i eti eatment of incomplete root canal fillings is not necessary when amalgam is used as a rettofilling because of its su]:)erior seal. Twenty-five teetb toot-end filled witb Cavit demonstrated a considerable amount of clissolutioti of tbis material. Tay et al. (149) examined tbe relatiotisbip between the size of periradiculai" lesiotis ancl tbe succe,ss or failure of apicoectomy iu 86 cases. Their findings indicated tbat large lesions (>12 mm in diameter) bealed as completely as tbe small ones, and removal of cysts increased tbe cbances for complete healijg. Flirsch et al. (150) examined the infiiieuce of clinical factors iti the healing of 572 cases follcm'ing periapical surgery up to 3 years. Factors found to be impcM tant for ptogtiosis included: exletit of bone destrtiction, cjtiality of root canal filling, age of patienl, and ptesetice of tnarginal buccal boue. Cases with smaller lesions, better root canal filling, atid ititact buccal cc:)t tical plates in older patients bealed better tban tbeir counterparts. hi a clinial examination, Goel et al. (151) replanted 40 maudibular molars ancl tised ZOE-
172

based cements, amalgam, Dutelou, or gold foil as root-end filling materials. Tbeir clinical assessment (biting force) up to 6 montlis showed gc:)ld foil to be the best matet ial, followed by amalgam, Durelon, and ZOE-based cements. They attril> uted the low success rate in teeth with ZOE/based cements as root-end filling mateiial to the ]Dre,sence of eugenol in tbese compounds. Mikkonen et al. (152) studied clinically and radiograpliically the success of apicoectomy in 174 teeth root filled with chlotc:)percha ancl guttapercha with and without atnalgatn. Their tesults sbowed locaticDU of teetb in tbe jaws, sex, age, and ottbograde or rettogiade methods bad no significant influence on success rate. Eack of periradictilar lesions, root lesorption, and presence of goodquality root canal fillings in teeth requiring periradicnlar stitgerv significantlv increased (be success rate. Reit aud I Iirscli (153) pet formed tetrograde root canal tteatnient using Hedsttotii liles and sodium bypocblorite to clean tbe canals and cblotoform-sofieued gntta-percba technique to obturate 35 teetb wbose t oot canals contained posts. Tbeir clinical and tadiograpbic examination performed "evety oUier year" sbowed evidence of 71% siiccessftil bealing of these cases. In a clinical retiospective study, Dorti &: Cartner (154) exatnined tbe success rate of 488 casc\s wbose root-end cavities bad been filled vvitli SnperEBA, IRM, and zinc-fiee high-copper amalgam for a minimum of 6 mouths to 10 yeras. Their clinical and radiographic examinafions showed tbat botb StijieiEBA and IRM bad significantly bigber success tates (ban amalgam. Tbe success rates were 75% for amalgatn, 91 % for IRM, and 95% for Su]DeiEBA. Grung et al. (155) assessed radiograpbic bealing of 477 teetb treated by endodontic siitgety for a period of 1-8 yeats and reported no cotrelalion between placement of rc3c:)t-end filling mate-rials atid bealing. Tbey found tbat 28% of tbe cases tteated willi rettogtade fillings failed, compared witb 4% in cases with ordiogiade root canal fillings. In tbeir cases, apical curettage was performed if tbe root canal cotild be completely pi elâred and adequately obturated; otbervvise apicoectomy was performed. This might have cattsed (be difference in tbe tesiilt. Furtbermore, tbey fotmd tbat there was a marked cottelation between tbe ]:)resence of a larger periapical rarefaction or perforation of lingual and buccal cot tical plates and tbe occurrence of incomplete bealing in fhe maxillary lateral incisors. Eustmann et al. (156) examined tbe relation of various operadve factors to the tt eatment results of apical sill get y iu 103 premolar or molar teetb. Tbev reported a significantlv higher success t ate iti toots obtut ated <2 tnni of tbe apex tban iti roots obtiit ated to or beyond tbe apex. In addition tliev' Ibund roots witli posts bad significantly more failures tban tbose witbotit posts. They attribnted the failures in these toc:)ts to the presence of fiacture before periapical surgery, or to (bat oi'd tetrofilling tnaterial contacting the post and formalion of cotrosin products. Using tbe data fiom tbe above stiidv, Friedman et al. (157) investigated the longterm prognosis of stirgical cases in premolars and molars for a period of 6 montlis to 8 years. Tbeir clinical and radiograpbic findings sbowed tbat only 44.1% of tbe roots were siicces,sful, aud tbe rest were eitber imsticcessfiil (33.1%) or doubtful (22.8%)). Furtbennore, tbeir tesiills sbow that wellobtutated cauals bave siguificautly bigber success rates tban poorly obturated canals. Rapp et al. (158) studied die effects c:)f various factors on 428 surgicallv treated eudodoutic cases atid fouud tbat pafients over 60 years of age bad tbe liigliest percentage of complete bealing. Tbeir explanafion was tbat canals in (bese patients are smaller and are easier to seal dm iug siirgei). Presence or absence of retrofilling bad no significant effect on bealing. In addition, tbey reported no significant diffetence between bealing wben diffetent toot-end filling materials were used. Tbey also reported tbat significantly better bealing was seen in teetb tbat wete petmanenlly restored following snrgerv. Waikakul & Punwulikoru (159) compared bealing in 66 teetb of ]ia(ients wbo bad eitber gold leaf or amalgam as root-end filling materials. A follow/ ii]3 of 6 (o 24 months showed no significant difference between tbe two groups. The authots recommended gold foil as an alternative to amalgam because of the following cbaracterisfics: its ease of stetilizafion, fewer or no residual particles, no setting time, cohesiveness, and its antibacterial effect. Ftatik et al. (160) evaltiated the long-term (10yeais) success of 104 teetb witb amalgam as a rooteud filling material. Tbey listed a case as a failure if there was a root-end radiolucency, even when a previous tadiograph indicated that bealing bad occurred. Tbese investigators reported tbat only 57% of cases retroftlled with amalgam were successful after a 10-year observation period and tbe rest failed in (he same time period. In a clinical and radiograpbic examination of 103 teeth whose toot-end cavitic\s bad been filled with amalgam of EBA, Pantschev et al. (161) fbund 52% and 57% succe.ss rates fbr atnalgam and EBA samples respectiveh 3 vears after surgery. Tbe percentage of teeth classified as uncertain was
173

23% for EBA and 19%; fbr amalgam. No significant differences wete noted between tbe success tates of tbe two treatment grotips. Jesslen et al. (162) evaluated healing of tootend filled teeth with amalgam or glass ionc^mer cement clinically and raclicDgtaiDhically and reported success rates of 90%) at 1 year aud 85% at 5 years in botb gioitps. Tbe autbors concluded tbat presetice of moisture dtiring periapical siitgety did tiot affect healing adversely ancl tecommended the glass ionomer as an alternative to amalgam as a toc:)t-eiid filling material. Examinafion of clinical stttdies using variotis loot-end filling materials shows tbat tbete are many variables in tbese inve,stigations. Tbe main vaiiables include: the number of cases, follow-up observation periods, matetials tested, diflerent procedures and tecbniqnes used dtiring tionstitgical and surgical endodontic treatments, and lack of standardization of evaluation criteria for qualitative results obtained in these studies. Because of the presence of tbese variables in tbese studies, tbey are diffictilt to compare with one anotbei. Except for studies by Finn et al. (148) and Grutig et al. (155), tbe rest are retrospective studies. Standardization oi: clinical parameters sucb as cleaning and sbaping of tbe root canal system, obturation of the toot canals, root-end preparations, taking radiographs, and post operative time intervals are easier to acbieve in |:)tospective studies compared with tbe retrospective ones. In addition, the information obtainecl in retrospective studies is testticted to available information. More wellcontrolled niulti-ceutre prospective stuches witb standardized clinical procedures along with large sam]3le sizes and appropriate statistical analysis are needed to investigate ancl compare tbe effectivenss of various rcjcH-eiid filling materials. Based on the teview of the litetatiiie i( a|3]ieats to date that exising tocjt-end filling materials do not po,sse,ss "ideal" characterisfics. Recently an experimental mateiial. Mineral Trioxide Aggregate (MTA), has been investigated in a series of tests: //( vitro dye leakage witbout and with blood contamination, in vitro bacterial leakage, SEM examination of re]Dlicas for marginal adaptation, setting time, compressive strengUi, solubility, antibacterial properties, cytotoxicity, im]:)lantation in bone, and an usage (est in toot-ends in dogs. Existing materials were used for comparison (I(i3-173). Tbe sealing ability of MTA was siipetior to tbat of amalgam or Su]ierEBA in botb dye and bactetial leakage tnethods, and was tiot adversely affected by bloc:)d cc:)ntamination (163-165). Tbe marginal adaptation of MTA was better than that of amalgam, IRM or SuperEBA (166). Tbe setting time of MTA was fotttid to be <3 liouts, wbicb is much longer (ban amalgam or IRM. Ckimpressive strength and solubility of MTA were similar to IRM and SnperEBA respecfively (167). Tbe antibacterial effects of MTA and (bree existing materials were investigated on facultative and stricdy anaerobic bacteria; none were found to be cotnpletely anfibactetial (168). Tbe cyUXoxicity of MTA was itivestigated b\' two metliods, agar overlay and tadiocbrotniutn release. Tbe MTA was tanked less cytotoxic dian IRM or SiipetEBA, but more cytotoxic tban amalgam in tbe agar overlay metbocl. It was found to be less cytotoxic tban atnalgam, IRM or SupetEBA vvbeu tbe radiocbtomium release method was used (1(>9). Wbeti tbe Ames test was used (o determine tbe mutagenificty of toot-end filling materials, MTA and commonly used root-eud filling matetial proved to be notitnntagenic (170). Witb implantafion of materials itl guitiea pig mandibles, tbere was no observable difference between MTA and SnperEBA (171). When root-end fillings of MTA or amalgam were placed in tbe premolar teetb of dogs and examined bislologically at vatious postopetative petiods up (o 18 weeks, tbete was less itiflammation around tbe root-eucls filled witb MTA, aud tbete was evideuce of bealiug of tbe sttrrouiiditig tissues. In addition, witb the longet-lerin teedi filled with MTA, new cementnm was found ou (be surface of tbe matetial; tbis was not (be case with amalgam (172). Similar peritadicular tisstie tesjDonses were noted when MTA was used as rootetid ftlling material in the maxillary incisots of monkeys (173). These studies supported die fiirtlier development of MTA for use as a root-etid ftlliug material in man.
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l();'i. T()RAtuM.|At) M, WAI.SON TF, Pit i FORD 1 R . Tbe s e a l i n g ability of a m i n e r a l t r i o x i d e a g g r e g a t e as a r e t r o g r a d e r o o t lilling m a t e r i a l . //s7icW 1993; 19: 5 9 t - 9 5 . K i i . 1 c)RAi!tNt;|Ai) M, fIi(;A RK, Mc;Kt;Ni)Ry D | , Piri FoRti TR. Elfects ol b l o o d c o n t a m i n a l i o n ol d y e l e a k a g e of root-c-ud lilling materials. / / w r W 1994; 20: 1 5 9 - 6 3 . 1(>5. roR\t(iN'E|Ai) M. FAE/\II R , IsJcrtERiNc. J D , P H I FORD T R . Bacteiial leakage of m i n e r a l t i i o x i d e aggrc-galc- as a rool e n d lilling m a t e r i a l . / & ( c W 1995; 21: 1 0 9 - 2 1 . 161'). T()RAi!tNK|AD M, Wii.DKR SMtt'ii i^ Ptri' FoRD 'LR. C o m p a r a tive investigation of m a r g i n a l a d a p t a t i o n of m i n e r a l Irioxide a g g r e g a t e a n d o t b e r c o m m o n l y u s e d rool end lilling m a t e r i a l s . /A'KC/OC/ 1995; 21: 29,5-99.
analysi.s of i b e inlluc-nce ofvai'ioii.s laclors u p o n bc-aling afler e n d o d o n t i c surgery. Int f Orat Surg \'-M2\ /.-25871. 147. Ai:tc)M:N M, MATIILA K . Follow-tip study of apicecloinizc-d molars, /iitj Orat Surg ]97iy. 5.-.33-40. 148. Fi.NNK K, NoRt) P(;, PERS.SI)\ G , t.t.NNARissc)N B. Retrograderool filling witb aiiialgani a n d Cavil. Oriit Surg Orrit Me(t Omt Pattiot 1977; / J ; ( i 2 1 - ( i 149. TAY WM, GAI.E lsA*!, H A K I Y F J . T b e inHtience of periapical
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178

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I-Jidod Dnit Iriilimiilnt I'>'>6: 12: 1(,1-I7S Piiiiliil ill Di'imiinl: .

(:op\riglil << .\liiiik.\giiaril 1996

Endodontics & Dental Traumatology

Root end filling materials: a review

Torabinejad & Pitt Ford

cavity preparations. Recently, O'Conner et al. (21)

Torabinejad & Pitt Ford

Root end filling materials

Torabinejad & Pitt Ford

Root end filling materials

Root end filling materials

Torabinejad & Pitt Ford

Root end filling materials

Torabinejad & Pitt Ford

Root end filling materials

Torabinejad & Pitt Ford

Root end filling materials

SZEREMETA-BROWER TL. \ AN GI RA | E . ZARI AE. A cc3ni])arison

B, ENCSTROM B , R e l r e a l m e n i ol e n d o d o n t i c fillings. Srand / DenI Res 1979: 87:217-24. ' '

22. 2.3. 24.

Torabinejad & Pitt Ford

dinal evaluation of the seal of endodontic reirolilling. / Endod \99(); 16:'M)7-\().

Longitudinal evaltiaiion of ihe seal of IRM root-end fill-

inga. /Endod 1994; 20; 250-2,

grade amalgam filling: a scanning electron microscopic

mcihocls used in root canal sealabilily sludies. Orat Surg

Oral Med (hal Pathol 1982; 53: 20,'i-H.

Root end filling materials

stie conditioners. / Prosthel Dent 1991; 66: (i569,

ity of filling materials. 7;;/ Endod / \980; 13: 131-8,

temporal)' filling materials. Int Endod / 1981; 14: 1214.

corroded and non-corroded denial silver amalgams.

nl' Bacteroides gingivalis on htiman pnlpal cells and t.929

cement as retrograde filling material. .\n experiment;il

Torabinejad & Pitt Ford

R e t r o g r a d e root lilling with composite- a n d a d e n l i n b o n d i n g a g e n t . \. l'jiih>ct Dent 'Imiinicitdt ]99l: 7: IIH25.

Effect of IRM r o o t - f i i d lillings o n h e a l i n g after r c p l a n i a lion.JFiidodo?! 1994; 20:'M]-b.

iceeloniy. A r e t r o s p e c t i v e study of 1,011) cases. Br Deni / U)70b; 729: 4 0 7 - 1 3 .

ant after aj)ic-oectomy. Oral Surg Orat Meet Omt Pnitiid

ol 1,000 ca.ses t r e a t e d by e n d o d o n t i c siirgeiy. hit J Oral .Suri,--1972; 7.-21,5-28.

1995; 79: 101-3.

radiohicencies on ibe suecess or failure of apicecloniies. /

IRM. /Fndod 1990; /6.-.391-3.

Norwegian county bo.spital; Follow-up lindings of 147

/'j(//orf 1995; 2/;5()9-7L

sults of apical suigc-ry in p r e m o i a r a n d m o l a r Ic-eth. //.f/of/1991; / 7; . 3 0 - 3 .

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