Basic ResearchTechnology

Sealing Ability of Three Materials in the Orifice of Root Canal Systems Obturated With Gutta-Percha
Stephen Jenkins, DDS, James Kulild, DDS, MS, Karen Williams, RDH, MS, PhD, William Lyons, and Charles Lee, DDS
Abstract
There were 130 single roots randomly assigned to one of 12 experimental or two control groups. Forty specimens each were sealed with 1, 2, 3, or 4 mm of Cavit, ProRoot MTA, or Tetric. After creation of a uniform orifice diameter, the smear layer was removed and the canal systems obturated using warm lateral compaction of gutta-percha (GP). GP was removed to the experimental depth, experimental materials placed in the orifice, and roots submerged in India ink in a vacuum flask. Specimens were demineralized and leakage measured using a 10 stereomicroscope and graded for depth of leakage by one calibrated, blinded rater. There was no significant interaction (p 0.05) between test materials and orifice depths, nor main effect of orifice depth (p 0.05). However, there was a statistically significant main effect of test materials with Tetric demonstrating a significantly better seal than Pro Root or Cavit (p 0.0001) irrespective of orifice depth. (J Endod 2006;32:225227)

Key Words
Coronal microleakage, coronal seal, intraorifice seal, orifice seal

From the Department of Endodontics, UMKC School of Dentistry, Kansas City, Missouri. Address correspondence to James Kulild, DDS, MS, UMKC School of Dentistry, Professor and Director, Postgraduate Endodontics, 650 E. 25th Street, Kansas City, MO 64108. E-mail address: kulildj@umkc.edu. 0099-2399/$0 - see front matter Copyright 2006 by the American Association of Endodontists. doi:10.1016/j.joen.2005.10.042

oronal microleakage can produce complete bacterial penetration of nonsurgical root canal treatment (1, 2). Furthermore, knowledge of the number and location of each root canal orifice is important in nonsurgical root canal therapy (3). Perhaps the use of a material to seal the orifice, in addition to the temporary restoration, could mitigate this bacterial leakage if that temporary restoration was lost or became unserviceable. Studies of orifice sealers have addressed ease of placement, ability to provide an adequate seal, and ease of removal; but all have evaluated materials placed to the same depth (4, 5). Without an adequate seal, long term success remains questionable (6) and failure to maintain the seal may expose obturated canals to microbes that could retard healing and create infection in the periodontal ligament or supporting osseous structures. Kakehashi et al. reported, through exposure of rat pulps, that presence of bacteria in the oral cavity contributes to the development of apical periodontitis (7). Vire reported that 59.4% of endodontically treated teeth failed because of lack of an adequate restoration (8). Balto reported that IRM, Cavit, and Dyract all demonstrated leakage when used as a temporary restoration (9). Schwartz et al. reviewed techniques and important strategies for temporization and final restoration of the access cavity with bonded materials (10). Some investigators have reported that significant coronal microleakage occurred when gutta-percha and sealer were used to obturate the root canal system, and then exposed to artificial saliva and India ink from 3 to 56 days. This leakage extended almost the complete length of the root canal system (1, 2). Roghanizad reported that 3 mm of Cavit, TERM, or amalgam placed in the orifice demonstrated less leakage than the positive control group, without an orifice seal, when exposed to methylene blue for 2 weeks (4). Pisano placed 3.5 mm of Cavit, IRM, or SuperEBA in the orifice of obturated root canals (5) and these teeth were exposed to saliva for 90 days and evidence of leakage was indicated by presence of absence of turbidity. All of the obturated, but unsealed, teeth leaked at 49 days, whereas 35% of the IRM and Super-EBA and 15% of the Cavit specimens demonstrated leakage. Thus, the addition of another barrier between the oral environment and the root canal system, at a depth yet to be determined, appeared to have a positive effect in reducing leakage and increasing possibilities for success. The purpose of this investigation was to examine the intraorifice sealing ability of three experimental materials at four different thicknesses after obturation of the root canal system.

Materials and Methods

There were 130 single-rooted teeth, with single root canal systems, stored at 100% humidity used. Before random assignment to groups, all teeth were cleansed, shaped, and obturated by the primary investigator (PI). Crowns were removed at the cementoenamel junction. All teeth were transilluminated under a dental operating microscope (Global Surgical Corporation, St. Louis, MO) and any tooth with a fracture was excluded. A #10 K-file (Kerr Corp, Orange, CA) was inserted and advanced until it was visualized at the apical foramen. The file was retracted 1 mm and working length was established at this level. A ProTaper SX file (Dentsply/Tulsa Dental Products, Tulsa, OK) was used to flare the orifice. One milliliter of 5.25% NaOCl (Clorox, Oakland, CA) was used between each instrument via a ProRinse Periodontal/Endodontic Irrigating Probe (Dentsply/Tulsa Dental Products, Tulsa, OK). ProTaper S1, S2, F1, F2, and F3 files was used sequentially per manufacturers instructions in a crown down technique. A 0.04 taper #35 and #40 ProFile (Dentsply/Tulsa Dental Products) were used to complete instrumentation. A uniform orifice diameter of 1.3 mm, at its widest point, was made using a #5 Gates Glidden bur (Dentsply/Tulsa Dental

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Basic ResearchTechnology
Three layers of nail polish (Revlon) were placed on all experimental teeth coating their root surface from root apex to the level of the cementoenamel junction. Positive controls were obturated, but not coated with nail polish. Negative controls were obturated and completely coated with nail polish, including the orifice. Samples were submerged in a vacuum flask containing India ink (Sigma), subjected to vacuum pressure of 75 torr for 30 minutes, and remained in the dye for seven days (11). After exposure to the dye, samples were rinsed with running water to remove ink from the external surface. Nail polish was gently removed with a #15 disposable safety scalpel (Miltex, Inc., Bethpage, NY). They were demineralized in 5% nitric acid (Sigma) for 5 days, with daily changes of acid (12) and dehydrated in ascending percentages of ethyl alcohol (Sigma). The samples were first placed in individual containers with 5 ml of 80% alcohol for 12 hours, replaced with 5 ml of 90% alcohol for 2 hours, and replaced with 100% alcohol for 2 more hours. To complete the clearing process, the roots were stored in 6 ml of methyl salicylate (Sigma) (13). The experimental materials were observed 360 degrees and leakage was measured by a calibrated examiner to the greatest penetration using a 10 stereomicroscope (Zeiss, Thornwood, NY) from the coronal extent of the orifice material to the nearest 0.1 mm. Data were analyzed using both descriptive and inferential statistics. To assess the interaction and main effects of test materials and orifice depth on depth of leakage, a two-factor ANOVA was used.

Figure 1. Experimental model.

Products) to a depth of 6 mm. Once instrumentation was completed, the canal was rinsed with two ml of 5.25% NaOCl, followed by 2 ml of 17% ethylenediaminetetraacetic acid (Moyco Union Broach, York, PA), and with a final rinse of 95% ethanol (Sigma, St. Louis, MO). Canals were dried with Lexicon sterile paper points (Dentsply/Tulsa Dental Products) followed by five seconds of air with a Micro-Air Unit (ASI Medical Inc., Englewood, CO) via 0.014 mm Capillary Tip (Ultradent, South Jordan, UT). Warm lateral compaction with the Endotec II (Medidenta, Woodside, NY) per manufacturers instructions was accomplished with Lexicon 0.04 gutta-percha points (Dentsply/Tulsa Dental Products) and ThermaSeal Plus (Dentsply/ Tulsa Dental Products). There were 120 teeth randomly divided among three experimental groups, with the remaining ten teeth being divided equally between positive and negative controls. The three experimental groups were further subdivided into four groups. Group 1: Forty single-rooted teeth, randomly divided into four groups of 10 teeth each. Cavit (3M ESPE, St. Paul, MN) was used to seal the canal orifice at depths of 1, 2, 3, or 4 mm in the orifice. Group 2: Forty single-rooted teeth, randomly divided into four groups of 10 teeth each. ProRoot MTA (Dentsply/Tulsa Dental Products) was used to seal the canal orifice at depths of 1, 2, 3, or 4 mm in the orifice. Group 3: Forty single-rooted teeth, randomly divided into four groups of 10 teeth each. Tetric (Ivoclar Vivadent, Amherst, NY) was used to seal the canal orifice at depths of 1, 2, 3, or 4 mm in the orifice. Positive Control: Five instrumented and obturated teeth with guttapercha at the level of the orifice. Negative control: Five instrumented and obturated teeth with three coats of nail polish (Revlon, New York, NY) sealing the entire tooth. The PI used the System B (SybronEndo, Orange, CA) to remove guttapercha to the experimental depth and verified the depth with a North Carolina periodontal probe (Hu-Friedy, Chicago, IL). Cavit (3M ESPE, St. Paul, MN), ProRoot MTA (Dentsply/Tulsa Dental Products), and Tetric (Ivoclar Vivadent), were placed into the orifice per manufacturers directions (Fig. 1). Each tooth was placed into a coded container and stored at 100% humidity for 48 hours to allow for sealer, Cavit, and MTA to set. Tetric is a light cured resin, but was exposed to 100% humidity for 48 hours to maintain consistency of treatment with the other experimental materials. 226

Results
Positive controls leaked at least 5 mm into the gutta-percha, and no leakage was observed in the negative control group. Figure 2 shows mean depth of penetration, in millimeters, for each material at various orifice depths. This figure demonstrates orifice preparation depth (x axis) versus the amount of leakage at each orifice depth (y axis). ANOVA showed no statistically significant interaction (p 0.05) between test materials and orifice depths, nor main effect of orifice depth (p 0.05). However, there was a statistically significant main effect of test materials. Tetric, at 1.49 mm mean penetration, demonstrated a significantly better seal than Pro Root, at 2.30 mm mean penetration, or Cavit, at 2.6 mm mean penetration, irrespective of orifice depth (p 0.0001) (Table 1). Evaluation of the effect size showed that type of material explained approximately 28% of leakage between groups, irrespective of orifice depths ( 2) .279).

Discussion
The results of this study indicated that, at all depths, Tetric demonstrated a significantly better seal than either MTA or Cavit. Leakage extended

Figure 2. Estimated marginal means of depth of penetration.

Jenkins et al.

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TABLE 1. Comparison of marginal means of depth of penetration for materials groups Standard Error
.15 .16 .15
0.0001).

Group

Mean

95% Confidence Interval Lower Bound

2.33 1.93 1.19

Upper Bound
2.95 2.58 1.79

Cavit ProRoot Tetric

2.64 2.26 1.49*

versely affect root canal sealers, and only demonstrates penetration of the ink, and not an ink and sealer mixture (19). Siqueira has demonstrated that temporary and core build-up fillings exposed to human saliva resulted in leakage (20). Salehrabi reported that the majority of extracted endodontically treated teeth lacked a full coverage restoration (21). Thus, the added benefit of an orifice barrier to reduce coronal leakage may help in retaining endodontically treated teeth. However, further research such as a long-term study using other composites, or use of bacteria, may provide a better basis for a true clinical study.

*Statistically significantly less than other two groups (p

Acknowledgment
This investigation was supported totally through the generous support of the Research Support Committee, UMKC School of Dentistry.

the entire length of all the experimental materials into the gutta-percha at the shallowest depth, i.e. 1 mm. However, leakage of Tetric was less than the other experimental materials at all experimental depths. Placement technique or sealing ability of the bonded composite were two possible factors for why Tetric leaked less than the other materials. Leakage, as a result of time, was not measured in this study, but could also be a factor. Uranga reported that Tetric did not demonstrate any leakage, whereas Cavit leaked significantly more than the other experimental materials (14). Tetric is a material that requires etching and use of a bonding agent before placement, but placement is still accomplished in approximately 2 minutes. Davalou found that a bonded coronal seal of either core paste and Tenure, or amalgam and Panavia, resulted in virtually no penetration (15). They also suggested that smear layer removal may have a direct influence on the success of the seal of a bonded resin (15). Because Tetric is a flowable composite, placement was easy. Wells reported that a secondary seal with a resin was both clinically easy and provided a good seal (16). Furthermore, while Tetric was expensive ($70.00 box/20 carps), very little material was required and it exhibited a contrasting shade to dentin. Although the intent is not to remove the orifice seal, the gutta-percha could be seen translucently through the Tetric at all depths and Tetric was easily removed with ultrasonics. The intent of an orifice seal is to be a definitive barrier of each root canal system. If post placement, or alternative core material, is to be placed in the root canal systems, the referring dentist can request that the orifice seal not be placed, or he can request the endodontist to place the post and core material. Tetric was used in this investigation because it is representative of a composite used by many practitioners and was also in a prior investigation (14). Mineral trioxide aggregate (MTA) leaked significantly more than the Tetric, was the most expensive material ($249.00/kit), the most difficult to mix consistently, and placement was more time consuming (3 min) than the other materials. Hardy found that a secondary seal was required over MTA in furcation restorations to minimize leakage (17). MTA was easily discerned from dentin and easy to remove with ultrasonics. Cavit leaked more than either MTA or Tetric. While inexpensive ($4.00/tube), Cavit was very easy to place (1 min). Given that the results demonstrated more leakage with 2 mm of material than with 1 or 3 mm, Cavit did not appear to provide a consistent seal. In fact, Cavit did not retard leakage until 3 mm of material was placed in the orifice. Webber stated that 3.5 mm of material to be the minimum thickness required in coronal restorations to prevent leakage (18). Our study demonstrated leakage at even 4 mm of material. Removal of Cavit was the easiest. The results of this study indicated that Tetric may have potential to provide an effective additional barrier to leakage at all depths studied. However, this study used India Ink for only 7 days. ztan demonstrated India Ink to be superior to methylene blue as it does not stain dentin, does not ad-

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