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Apical dye penetration with four root canal

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ARTICLE in JOURNAL OF ENDODONTICS DECEMBER 1992
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JOURNAL OF ENDODONTICS
Copyright 1992 by The American Association of Endodontists

Printed in U.S.A.
VOL. 18, NO. 11, NOVEMBER1992

Apical Dye Penetration with Four Root Canal Sealers

and Gutta-Percha Using Longitudinal Sectioning
Sriwalee Limkangwalmongkol, DDS, MDSc, Paul V. Abbott, BDSc, MDS, FRACDS(Endo), and
Anthony B. Sandier, BDS, HDDent

to their chemical composition. The most common sealers

have bases of calcium hydroxide, zinc oxide-eugenol, or resin
materials.
Numerous studies using various techniques have been performed to quantitatively assess the leakage potential of root
canal filling materials. The main techniques used include
passive dye penetration (2, 3), radioactive isotope penetration
(4, 5), electrochemical leakage tests (6, 7), bacterial penetration (8, 9), and scanning electron microscopic analysis (10,
11). There appears to be little correlation between the results
of the many tests which may be a function of the many
variations in experimental techniques, root canal anatomy,
or the ability of the operators. The effect of entrapped air in
passive dye penetration studies may also lead to variations in
results (12-14).
A recent study (l) compared the apical leakage of four root
canal sealers representing each of the above chemical groups:
Apexit (Ivoclar/Vivadent, Schaan, Leichtenstein), Sealapex
(Kerr Co., Romulus, MI), Tubli-Seal (Kerr Co.), and AH-26
(De Trey Freres, Zurich, Switzerland). A centrifuge was used
to reduce the effect of entrapped air and the level of dye
penetration was assessed with a transverse sectioning technique. When using a transverse sectioning technique, some
tooth structure (equivalent to the thickness of the saw blade)
is lost during each horizontal cut. This could affect the accuracy of the results since the loss of tooth structure is in the
same direction as the direction of measurement of the dye
penetration. An alternative method for assessing the extent of
dye penetration is to use a longitudinal sectioning technique.
The aim of this study was to determine the relative sealing
ability of the same four root canal sealers with laterally
condensed gutta-percha using a longitudinal sectioning
method.

The purpose of this study was to compare the level

of apical dye penetration when different sealers
were used with lateral condensation of gutta-percha. Fifty teeth with single root canals were biomechanically prepared using the step-back technique
and irrigation with 15% ethylenediaminetetraacetic
acid with cetrimide and 1% NaOCI solutions. The
teeth were divided into five groups of 10 teeth each.
The control group root canals were filled with laterally condensed gutta-percha without sealer and
the other four groups were filled with laterally condensed gutta-percha and either Apexit, Sealapex,
Tubli-Seal, or AH-28 sealer. After storage in 100%
humidity at 37C for 48 h, the root surfaces were
coated with nail varnish (except at the apex), placed
in 2% methylene blue dye solution, and centrifuged
at 30 x g for 3 min. The roots were sectioned
longitudinally to determine the following mean levels
of dye penetration: AH-26, 0.48 ram; Apexit, 1.33
mm; Sealapex, 4.59 mm; Tubli-Seal, 5.58 mm; and
gutta-percha alone, 7.99 mm. This study demonstrated that a root canal sealer should be used in
conjunction with laterally condensed gutta-percha
and that AH-26 sealer had significantly less dye
penetration than the other three sealers while Apexit
had significantly less dye penetration than Sealapex
and Tubli-Seal. There was no significant difference
between Sealapex and Tubli-Seal.

One of the objectives of endodontic treatment is to totally fill

the root canal system after it has been cleaned and shaped.
The most commonly used core filling material is gutta-percha
but this material does not seal the canal when used alone (1).
Therefore, a root canal sealer, or cement, is required to adhere
to the dentin and to fill the irregularities and minor discrepancies between the core filling material and the canal walls,
thus providing a seal. The sealer also acts as a lubricant during
the obturation procedure and it may fill any patent accessory
canals and multiple foramina. Many sealers have been developed for use in root canals. They can be classified according

MATERIALS AND METHODS

The materials and methods used in this study were identical
to those of the earlier study (1), except for the number of
teeth used and the method of sectioning the teeth.
Fifty single-rooted human teeth with a single root canal
were used in this study. The age, sex, and reasons for extraction were not recorded. Preoperative radiographs were taken
from both mesiodistal and faciolingual directions. The teeth
and radiographs were screened and discarded if any of the

535

536

Limkangwalmongkol et al.

following were noted: the root curvature was greater than 5

degrees, a root fracture was evident, the apex was incompletely
formed or larger than a #25 K-type file, or if any bifurcating
canals, fins, ribbon-shaped canals, or extreme calcifications
could be seen. The teeth were stored in Milton Anti-bacterial
Solution (Richardson-Vicks Pty Ltd., Villawood, Australia),
a 1% sodium hypochlorite (NaOC1) solution, for 3 days to
remove organic debris and then they were stored in distilled
water.
The crowns were removed at the cementoenamel junction
using a high-speed fissure bur to eliminate any variables in
access preparation and a barbed broach was used to remove
the pulp. The working length was determined by passing a
#10 K-type file into the canal until the tip was just visible at
the apical foramen and then subtracting 1 mm from this
length.
The canals were cleaned and shaped with K-type files using
a serial (step-back) technique with recapitulation of files to
establish a progressively tapering root canal preparation. The
apical portion of the canal was enlarged to a minimum #30
and maximum #50 file, depending on the size of the original
canal. Any tooth requiring a size larger than #50 file for
adequate cleaning was discarded and replaced with another
tooth. The coronal two-thirds of each canal was flared using
#2 and #3 Gates Glidden burs and the apical third was flared
with hand files. After each instrument was used, the canals
were irrigated with 2 ml of 1% NaOCI and 2 ml of EndoSofl
(AdLab, Alfred Cove, Australia), a 15% solution of ethylenediaminetetraacetic acid with cetrimide. The irrigating solutions were delivered through a 25-gauge needle which was
placed as far as possible into the canal without allowing the
needle to touch the canal walls. The total amount of irrigant
used in each canal was 30 ml. On completion of the instrumentation process, a #10 file was passed 1 mm through the
apical foramen to remove any dentinal plugs and to ensure
that the foramen was patent for dye penetration.
After drying the canals with paper points, standardized
Antaeos gutta-percha cones (United Dental Manufacturers
Inc., West Palm Beach, FL) were selected as master points.
The fit of each master point was assessed by exposing mesiodistal and faciolingua] radiographs to determine whether the
point was fully seated to the working length.
The teeth were randomly selected and divided into five
groups of 10 teeth each (four experimental groups and one
control group). All the teeth except the control teeth were
filled with a root canal sealer and gutta-percha points using
the lateral condensation technique. In the control group, a
sealer was not used. The sealers were used as follows: group
1, Apexit; group 2, Sealapex; group 3, Tubli-Seal; group 4,
AH-26; control group, gutta-percha alone (no sealer).
The sealers were mixed according to the manufacturers'
directions and were introduced into the canal using a spiral
root filler (Zipperer; Vereinigte Dentalwerke, Munich, Germany) which was kept 3 to 4 m m short of the working length.
This process was repeated twice to ensure that an adequate
amount of sealer was placed in each canal. The master guttapercha point was coated with sealer and seated in the canal
to the full working length. A D11T spreader (Star Dental,
Philadelphia, PA) was then inserted into the canal to a level
that was 1 to 2 mm short of the working length. Lateral
condensation with nonstandardized Antaeos (United Dental
Manufacturers Inc.) fine-fine gutta-percha accessory points

Journal of Endodontics

was carried out until the entire canal was obturated. Excess
gutta-percha was removed and the gutta-percha in the coronal
third of the canal was vertically condensed with a plugger.
Two final radiographs were taken in the mesiodistal and
faciolingual directions to evaluate the root canal filling. Obturation was considered to be adequate when no voids were
discernible and all visible canal spaces were filled completely.
If the obturation appeared to be inadequate, the root canal
filling was removed and the canal was refilled.
The access cavities were sealed with Cavit (ESPE GmbH,
Seefeld, West Germany) and the teeth were placed in a
humidor for 1 to 3 wk with 100% humidity at 37C to ensure
that the sealers set in an environment that simulated the
clinical situation in which they are designed to be used.
The tooth roots were coated with two layers of clear nail
varnish (Revlon, New York, NY) except for the apical 2 to 3
mm. At this stage the control group was further subdivided
into two equal groups, the positive and negative controls.
Teeth in the positive control group had the roots coated with
nail varnish except for the apical 2 to 3 mm in the same
manner as the experimental groups. They were used to test
the sealing ability of gutta-percha when used without a sealer.
Teeth in the negative control group had the entire root surface
coated with nail varnish and were used to test the ability of
the nail varnish to seal the root against dye penetration under
the experimental conditions used in this study.
After the varnish was completely dry, each tooth was placed
in a 12-ml centrifuge tube with the apex pointed toward the
open end of the tube. Methylene blue dye solution (2%, pH
7) was added to each tube until the root was fully submerged
(Fig. 1). The teeth were then centrifuged for 3 min at 30 x g
using a centrifuge (ECCO, West Germany). The teeth were
removed from the dye solution, rinsed in running tap water
and embedded in epoxy resin (Formatray; Kerr Co.).
The experimental teeth were sectioned longitudinally using
a low-speed Isomet diamond saw (Buehler Ltd., Lake Bluff,
NY) in a direction approximately parallel to the long axis of

A centrifuge tube

Level of methylene blue dye

An experimental root covered

completely with dye solution

FIG 1. Diagrammatic representation of a prepared tooth root in a

centrifuge tube and completely submerged in methylene blue dye
solution.

Vol. 18, No. 11, November 1992

Apical Dye Penetration

537

TABLE 1. Mean dye penetration values

10

No. of

Group

Sealer

1
2
3
4
5

Apexit
Sealapex
Tubli-Seal
AH-26
No sealer
Positive control
Negative control

Specimens

Mean Dye
Penetration
(ram)

SD

Range

10
10
10
10

1.33
4.59
5.58
0.48

0.64
3.02
1.94
0.18

0.44-2.35
0.59-8.71
1.83-8.58
0.24-0.82

5
5

7.99
0

1.74
--

4.74-9.86
--

(ram)

mm.

i
Apexit

=,

I I

'

Sealapex

Tubliseal

,
AH26

Gutta-Percha

FiG 2. The range of dye penetration for each group.

FtG 3. Examples of positive (/eft) and negative (right) control teeth

after longitudinal sectioning. The positive controls show dye penetration along the entire length of the root canal fillings while the negative

control teeth have no dye penetration.

the tooth and through the apex. After cutting, the specimens
were examined under a microscope (x50 magnification) and
the end point of dye penetration was determined as the point
where dye no longer penetrated the filling material, its interface with the dentinal walls, or the dentinal tubules. The
distance from the end of the root filling to the end point of
dye penetration was measured and recorded in millimeters.
Each root was measured five times on 5 different days by the
same evaluator to reduce any possible error in measurement.
Any measurements which differed by more than 0.5 mm were
evaluated again.
All results obtained were submitted for statistical analysis
using Snedecor's F test and the Student's t test. Snedocor's F
test was used to test for the equality of the variances among
the experimental groups and Student's t test was used to
determine whether there were any statistically significant differences among the experimental groups at the 1% level of
significance (p < 0.01).

RESULTS
Dye penetration was observed in all specimens except the
negative control teeth. The measurements of maximum linear
dye penetration were made in order to quantify the relative
leakage of each group and the mean dye penetration values
are summarized in Table 1. The lowest mean level of dye
penetration was in the AH-26 group followed by (in ascending
order of dye penetration): Apexit, Sealapex, Tubli-Seal, and
the positive controls. Figdi'e 2 illustrates the range of dye

FiG 4. Representative examples of experimental teeth from group 1

(Apexit) after longitudinal sectioning.

penetration for each group and Figs. 3 to 7 show typical

examples of dye penetration for each group.
In all comparisons of the variances with Snedecor's F test,
the value of the F ratio fell within the critical value at the 1%
level of significance (p < 0.01) for the appropriate degrees of
freedom. Therefore, Student's t test was used to determine
whether there were significant differences between the means
of the five groups at the 1% level of significance (p < 0.01).
Analysis of the data showed significant differences between
all groups except between the Sealapex and Tubli-Seal groups.

538

Limkangwalmongkol et al.

FIG 5. Representative examples of experimental teeth from group 2

(Sealapex) after longitudinal sectioning.

FIG 6. Representative examples of experimental teeth from group 3

(Tubli-Seal) after longitudinal sectioning.

FIG 7. Representative examples of experimental teeth from group 4

(AH-26) after longitudinal sectioning,

In the experimental teeth, both AH-26 and Apexit performed

well, but AH-26 showed significantly less leakage than Apexit.
DISCUSSION
A previous study (i) tested the same four root canal sealers
used in this study but a different method was used to assess
the dye penetration. In that study, the tooth roots were

Journal of Endodontics

sectioned transversely whereas longitudinal sectioning was

used in the current study. This earlier study had similar results
to the present study but the differences between the means
were only significant when AH-26 was compared with the
other sealers. The other sealers were not significantly different
from each other, although Apexit had less leakage than TubliSeal which in turn had less than Sealapex. As in the current
study, the results of the positive control group reaffirmed that
gutta-percha should be used with a sealer when laterally
condensed.
In both the earlier and the current studies, a centrifuge was
used to place the tooth and dye solution under pressure since
Kersten et al. (15) have suggested that apical leakage was
enhanced by pressure. In addition, the use of a centrifuge
eliminates some of the effects of any air that may have been
entrapped in voids within the root canal filling. This was
reported in a recent study where the centrifuge method was
shown to be more reliable than passive dye studies in demonstrating the true extent of a void (14). The centrifuge was
used to force the dye solution through any defects in the root
canal filling rather than waiting for capillary action to allow
fluid movement by passive penetration.
The transverse sectioning method used in the earlier study
(1) has a disadvantage in that some of the tooth structure was
lost during each cut due to the thickness of the cutting blade.
In order to overcome this problem, the longitudinal sectioning
method was used in this study. However, there are also some
disadvantages of the longitudinal sectioning method. These
were:
1. The quality of the root canal filling could not be assessed
since only one plane of the root canal filling could be examined.
2. Any lateral canals, secondary canals, and cracks were
difficult to detect.
3. Additional cuts were needed to obtain the correct direction to cut through any canal curvatures.
The results of these two studies differed in that Apexit was
found to have a significantly lower mean dye penetration
when compared with Tubli-Seal and Sealapex in the current
study, whereas this difference was not significant in the first
study. The reasons for this difference in results are not readily
apparent but may be related to the different sample sizes, any
of the disadvantages mentioned above, or differences during
any of the various stages of treatment (such as cleaning,
shaping, irrigating, sealer placement, condensation of guttapercha, or tooth processing and sectioning techniques).
Apexit, the new calcium hydroxide-based root canal sealer,
provided a better seal than another calcium hydroxide-based
sealer, Sealapex, and the zinc oxide-eugenol-based, Tubli-Seal.
However, AH-26 provided a significantly better apical seal
when compared with the other three sealers and it also had
the best working characteristics. Based on the results of the
dye study and the previous study (1), there is insufficient
evidence to support the use of sealers with bases of calcium
hydroxide or zinc oxide-eugenol in preference to the resinbased AH-26. However, it is important to remember that the
results of dye penetration studies indicate only the relative
sealing ability of root canal fillings in vitro and they do not
indicate their ability to prevent the penetration of bacteria in
to filled root canals in vivo. In addition, before accepting a
new material for routine clinical use, further experiments
should also be performed to evaluate other aspects of a

Vol. 18, No. 11, November 1992

material's physical and biological properties such as biocompatibility, solubility, disintegration, radiopacity, and dimensional stability.
Drs. Limkangwalmongkol, Abbott, and Sandier are members of the Dental
School, University of Western Australia, Perth, Australia. Address requests for
reprints to Dr. Paut Abbott, Suite 19, Perth Surgicentre, 38 Ranelagh Crescent,
South Perth, WA 8151 Australia.

References
1. Limkangwalmongkol S, Burtscher P, Abbott PV, Sandier AB, Bishop
BM. A comparative study of the apical leakage of four root canal sealers and
laterally-condensed gutta-percha. J Endodon 1991 ;17:495-9.
2. Massler M, Ostrovsky A. Sealing qualities of various filling materials. J
Dent Child 1954;21:228-34.
3. Grieve AR. Sealing properties of cements used in root filling. Br Dent J
1972;132:19-22.
4. Dew PR, Ingle JI. Isotope determination of root canal failure. Oral Surg
1955;8:1100-4.
5. Marshall FJ, Massler M. The sealing of pulpless teeth evaluated with
radioisotopes. J Dent Med 1961;t6:172-84.

Apical Dye Penetration

539

6. Jacobsen SM, yon Fraunhofer JA. The investigation of microleakage in

root canal therapy: an electrochemical technique. Oral Surg 1976;42:817-23.
7. Mattison GD, von Fraunhofer JA. Electrochemical microleakage study of
endodontic sealer cements. Oral Surg 1983;55:402-7.
8. Kronman JH, Goldman M, Goldman LB, Coleman E, Kliment CK. Microbiologic evaluation of poly-HEMA root canal filling material. Oral Surg 1979;
48:175-7.
9. Kos WL, Aulozzi DP, Gerstein H. A comparative bacterial microieakage
study of retrofilling materials. J Endodon 1982;8:355-8.
10. Torabinejad M, Skobe Z, Trembly PL, Krakow AA, Gron P, Martin J.
Scanning electron microscopic study of root canal obturation using thermoplasticized gutta-percha. J Endodon 1978;4:245-50.
11. Lugassy AA, Yee F. Root canal obturation with gutta-percha: A scanning electron microscopic comparison of vertical compaction and automated
thermatic condensation. J Endodon 1982;8:120-5.
12. Sp&ngberg LSW, Acierno TG, Yongbum CB. Influence of entrapped air
on the accuracy of leakage studies using dye penetration methods. J Endodon
1989;15:548-51.
13. Goldman M, Simmonds S, Rush R. The usefulness of dye penetration
studies re-examined. Oral Surg 1989;67:327-32.
14. Oliver CM, Abbott PV. Entrapped air and its effects on dye penetration
of voids. Ended Dent Traumato11991 ;7:135-8.
15. Kersten HW, Ten Cate JM, Exterkate RAM, Moorer WR, Thoden Van
Velzen SK. A standardized leakage test with curved root canals in artificial
dentine. Int Ended J 1988;21:191-9.

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