CLINICAL EBOOK SERIES

UPDATES IN
POWERED BY

ENDODONTICS
DECEMBER 2017

2 C E C R E D I T S

ROOT CANAL IRRIGANTS

Root Canal Irrigants: A

Review of Their Interactions,
Benefits, and Limitations
Amit Jena, MDS; Sanjit Kumar Sahoo, MDS; and
Shashirekha Govind, MDS

2 C E C R E D I T S

ENDODONTIC MATERIALS

Bioactive Materials in
Endodontics: An Evolving
Component of Clinical
Dentistry
Satyajit Mohapatra, MDS; Swadheena Patro, MDS; and
Sumita Mishra, MDS

SUPPORTED BY AN UNRESTRICTED GRANT FROM PARKELL • Published by AEGIS Publications, LLC © 2017
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are often genuinely interested in keeping up- SPECIAL PROJECTS COORDINATOR

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to-date with developments in various aspects BRAND MANAGER
of their field. This special Compendium eBook Amelia Falcone
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is designed to provide such desirable informa- Bill Noone
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Claire Novo
continuing education credits.
EBOOK DESIGN
This Updates in Endodontics eBook contains two CE ar- Jennifer Barlow

ticles to increase practitioners’ knowledge of endodontics

COVER
topics. The articles are entitled “Root Canal Irrigants: A © AEGIS Publications, LLC

Review of Their Interactions, Benefits, and Limitations” Copyright © 2017 by AEGIS Publications, LLC. All
and “Bioactive Materials in Endodontics: An Evolving rights reserved under United States, International and
Pan-American Copyright Conventions. No part of this
Component of Clinical Dentistry.” publication may be reproduced, stored in a retrieval
system or transmitted in any form or by any means
The first CE article describes the vital role that irrigation without prior written permission from the publisher.
PHOTOCOPY PERMISSIONS POLICY:
plays in successful endodontic treatment. Available litera- This publication is registered with Copyright
Clearance Cen­ter (CCC), Inc., 222 Rosewood
ture and studies demonstrate advantages and limitations of Drive, Danvers, MA 01923. Per­mission is granted
for photocopying of specified articles provided
a variety of irrigants. Understanding the mode of action of the the base fee is paid directly to CCC.
Printed in the U.S.A.
various available and commonly used solutions is important
for optimal irrigation. New developments in the composition
of irrigating solutions are likely to contribute to advance-
ments in safety and efficacy in the future.
The second CE article addresses the complexity of the pulp
root canal and the difficulty in achieving complete disinfection, Chief Executive Officer
Daniel W. Perkins
shaping, and filling to prevent bacterial infiltration. Newer bio- President
materials for use in endodontics, such as mineral trioxide ag- Anthony A. Angelini
Chief Operating Officer
gregate and calcium phosphate-based materials, promote pulpal Karen A. Auiler
and periapical healing. This article examines such bioactive ma- Corporate Associate
Jeffrey E. Gordon
terials, including the potential of injectable bone substitutes.
Subscription and CE information
This eBook is among a variety of Compendium resources Hilary Noden
877-423-4471, ext. 207
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tics. For more clinical articles and CE in this subject area, we
encourage you to visit dentalaegis.com/cced/endodontics.

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Louis F. Rose, DDS, MD

Editor-In-Chief AEGIS Publications, LLC
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2 COMPENDIUM EBOOK SERIES December 2017

CONTINUING EDUCATION 1 ROOT CANAL IRRIGANTS

Root Canal Irrigants:

A Review of Their Interactions,
Benefits, and Limitations
Amit Jena, MDS; Sanjit Kumar Sahoo, MDS; and Shashirekha Govind, MDS

ABSTRACT: Endodontic treatment success depends on a combination of appropri-

ate instrumentation, effective irrigation and decontamination of root canal spaces to
apices, and obturation of the root canals. Irrigation of the root canal is paramount in
determining periapical tissue healing. This article reviews presently available root
canal irrigants, their interactions, advantages, and limitations. For this review, the au-
thors performed a Medline search for all English language articles published through
January 2014 with “root canal irrigants” and “endodontic irrigants” as keywords.

LEARNING OBJECTIVES

• Discuss the significance of • Delineate the interactions, • Describe the modes of action
root canal irrigation as it advantages, and limitations of of various commonly used
relates to periapical tissue current root canal irrigants irrigating solutions
healing

W
hen dental pulp undergoes
pathological changes due
to trauma or caries, micro-
organisms enter the pulp
chamber and invade the
anatomic irregularities of the root canal
system.1 Infection of the root canal spac-
es occurs most frequently as a sequela to
a profound caries lesion.2 The objective of
endodontic treatment is to prevent or elimi-
nate infection within the root canal. In ev-
ery root canal system there are spaces that
cannot be cleaned mechanically and where
cleaning is dependent on thorough chemo-
mechanical debridement of pulpal tissue,
dentin debris, and infective microorganisms.
Infection control is critical for the success
of nonsurgical endodontic treatment.
DISCLOSURE: The authors had no disclosures to report.
Irrigation is complementary to instrumen-
tation in facilitating the removal of pulp tissue
and/or microorganisms. There are a number
of ideal requirements of a root canal irrigant.
It should provide a broad spectrum of anti-
microbial activity while flushing out debris
from the root canal. It should be nontoxic and
biocompatible in nature, able to sterilize the
canal and dissolve the smear layer. The root
canal irrigant should have good lubricating
action along with low surface tension to be
able to flow into inaccessible areas. Finally,
the irrigant should facilitate dentin removal
but not weaken the tooth structure.
In light of the importance of infection con-
trol, the aim of this review is to analyze the
relevant literature on root canal irrigating
solutions, their actions, and interactions. For

www.compendiumlive.com December 2017 COMPENDIUM EBOOK SERIES 3

 CONTINUING EDUCATION 1
this review article the authors performed a
Medline search for all English language ar-
ticles published through January 2014.
Sodium Hypochlorite (NaOCl)
Sodium hypochlorite (NaOCl) was first intro-
duced during World War I by chemist Henry
Drysdale Dakin and surgeon Alexis Carrel
for treating infected wounds through the use
of a buffered 0.5% solution of NaOCl. It is,
therefore, also known as “Dakin’s solution.”
In 1936 Walker first suggested its use in root
canal therapy, and in 1941 Grossman demon-
strated the tissue-dissolving ability of chlo-
rinated soda when used in double strength.
Spangberg in 1973 said that 0.5% of NaOCl
has good germicidal activity.3
NaOCl Mechanism of Action
At body temperature, reactive chlorine in
aqueous solution exists in two forms: hypo-
chlorite ion (OCl-) and hypochlorous acid
(HOCl). At acidic or neutral pH, chlorine
exists predominantly as HOCl, whereas at
high pH of 9 and above OCl- predominates.
Hypochlorous acid is responsible for the an-
tibacterial activity; the OCl- ion is less effec-
tive than the undissolved HOCl. Hypochloric
acid disrupts several vital functions of the
microbial cell, resulting in the cell death.4 As
a disinfectant, HOCl is more effective than
OCl-. By controlling the pH, one can ensure
that the more effective bactericide HOCl will
remain the dominant species in solution. The
germicidal potency of HOCl is approximately
80 times more than OCl- ion.
Concentration of Sodium Hypochlorite
for Endodontic Usage
In endodontic therapy NaOCl solutions are
used in concentrations that vary from 0.5%
to 5.25%.5 Also available are unbuffered so-
lutions at pH 11 to 12 in concentrations rang-
ing between 0.5% and 5.25%, or the so-called
Dakin’s solution, which is a buffered 0.5%
4 COMPENDIUM EBOOK SERIES December 2017
ROOT CANAL IRRIGANTS
solution at pH 9.5,6 There is no difference be-
tween these two solutions with respect to tis-
sue dissolution or antibacterial efficiency.5,7
NaOCl dissolves pulpal remnants, organic
compounds of dentin, and organic compo-
nents of the smear layer.8,9 Moreover, neutral-
ization or inactivation of lipopolysaccharides
has been reported with NaOCl.10,11 However,
NaOCl is not able to remove the smear layer
Fig 1.
by itself, as it dissolves only organic material.12
The dissolving capacity of NaOCl is significant-
ly better than all other commonly used irrigants8
but is dependent on the concentration of the so-
lution. The higher the concentration, the greater
the cytotoxicity.3,13 Regular replenishing of NaOCl
irrigant solution is necessary for better tissue-
dissolving capability during root canal treatment.
NaOCl used in concentrations of 0.5% and 1%
wt/vol have enhanced tissue-dissolving capabil-
ity, antimicrobial activity, and biocompatibility
and are recommended for routine clinical use.5 It
should be used throughout the instrumentation
phase. However, use of NaOCl as the final rinse
following ethylenediaminetetracetic acid (EDTA)
or citric acid should be avoided because it rapidly
produces erosion of the canal wall dentin.14 “Full
strength” 5.25% NaOCl can have a detrimental
effect on dentin elasticity and flexural strength.
Hypochlorite in some situations may increase the
risk of vertical root fracture.15 This is most likely
due to the proteolytic action of concentrated hy-
pochlorite on the collagen matrix of dentin.
Increasing the Efficacy of
Sodium Hypochlorite
NaOCl should not be diluted with water for root
canal irrigation, as this reduces its antibacterial
and tissue-dissolving properties.16 The volume
of irrigant is also clinically relevant, as an in-
crease in volume correlates with reduction of
intraradicular microorganisms and improved
canal cleanliness.17,18 Yamada et al recommend-
ed 10 ml to 20 ml of irrigant for each canal.
With regard to timing, the greater the contact
time, the more effective the NaOCl irrigant is.
CONTINUING EDUCATION 1
This is especially important in necrotic cases
where 5.25% of NaOCl used for 40 minutes
was found to be effective.3 The clinician should
be cognizant of the working time of NaOCl,
bearing in mind the fact that rotary root canal
preparation techniques have expedited the
shaping process.19
Another factor is temperature. Warm NaOCl
dissolved organic tissues significantly better
than unheated solutions.20 A rise in tempera-
ture by 25oC increased NaOCl efficacy by a fac-
tor of 100.21 The ability of 1% NaOCl at 45oC
to dissolve human dental pulps was found to
be equal to that of a 5.25% solution at 20oC.21
However, there are no clinical studies available
at this point to support the use of heated so-
dium hypochlorite. Once heated but not used,
NaOCl solution must be discarded immediately,
because its effectiveness is exhausted.22
The use of side venting irrigation needles
helps to move the irrigant sideways in a whole
canal and avoid periapical extrusion. Shaping
of the root canal must be to at least size #25
at the apex for irrigation needles to reach the
more apical portions of the canal. The irrigant
does not move apically more than 1 mm be-
yond the irrigation tip, therefore deep place-
ment with small-gauge needles enhances ir-
rigation.23 During rinsing, the needle is moved
up and down constantly to produce agitation
and prevent binding or wedging of the needle.
Apical negative pressure irrigation will im-
prove the irrigation dynamics and enhance
interaction between NaOCl and the root canal
wall in the apical portion of the canal.
Passive ultrasonic activation of NaOCl after
canal preparation is an alternative approach
to improve its effectiveness, as this will “ac-
celerate chemical reactions, create cavita-
tional effects, and achieve superior cleansing
action.”24 Factors that influence ultrasonic
irrigation include frequency and duration of
agitation, size and position of the insert, and
concentration and volume of NaOCl pres-
ent inside the root canal. It appears best to
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ROOT CANAL IRRIGANTS
insert a slim, non-cutting instrument in a
controlled fashion after canal preparation.25
Laser-assisted root canal disinfection seems
to have the potential to improve fluid dynam-
ics within the root canal.
NaOCl solutions containing 0.5% and 5%
chlorine stored at 4oC displayed satisfacto-
ry stability at 200 days, whereas 5% NaOCl
decomposed rapidly when stored at 24oC.26
Therefore, it is recommended to store NaOCl
solutions in a refrigerator and in dark bottles
to avoid degradation by light.27
Sodium Hypochlorite’s Effect on
Mechanical Properties
Cavalleri et al have shown that using sodium
hypochlorite as an irrigating solution in root
canals for short-term contact (several min-
utes, as is the case in clinical practice) does not
alter the surface structure of the files through
corrosion and does not cause any risk of frac-
ture of nickel-titanium (Ni-Ti) instruments.28
NaOCl irrigation decreases bond strength
between resin cements and dentin, because
hypochlorite affects the polymerization of the
resin sealer.29,30 Agents such as ascorbic acid
or sodium ascorbate completely reverse the
reduction of bond strength.31
NaOCl and chlorhexidine (CHX) are not solu-
ble in each other, and a brownish orange precipi-
tate is formed, which is a carcinogenic product,
parachloroanaline (PCA). PCA has mutagenic
potential. Atomic absorption spectrophotom-
etry has indicated that the precipitate contains
iron, which may be the reason for the orange
development.32 This reaction coats the canal
surface and significantly occludes the dentinal
tubules and affects the seal of the root canal.33
It would appear prudent to minimize the for-
mation of PCA by washing away the remaining
NaOCl with alcohol or EDTA before using CHX.
Precautions to Take
Sodium hypochlorite is caustic if accidentally
extruded into periapical tissue or adjacent
December 2017 COMPENDIUM EBOOK SERIES 5
 CONTINUING EDUCATION 1
anatomical structures such as the maxillary
sinus.34 Emphysema develops within 10 to 20
minutes if accidentally injected into periapical
tissue. Edema and paresthesia may result due
to the tissue-dissolving capability of NaOCl.
Because the potential for spread of infection
is related to tissue destruction, medications
such as antibiotics, analgesics, and antihista-
mines should be prescribed accordingly.
Chlorhexidine Digluconate (CHX)
Chlorhexidine digluconate (CHX) was devel-
oped in the late 1940s in the research labora-
tories of Imperial Chemical Industries Ltd.
(Macclesfield, England). Amongst a series of
polybisguanides synthesized to obtain anti-
bacterial agents, chlorhexidine was the most
potent of the tested bisguanides.35 It is a strong
base and is most stable in the form of its salts.
The original salts were chlorhexidine acetate
and hydrochloride, both of which are relative-
ly poorly stable in water.36 Hence, they have
been replaced by chlorhexidine digluconate.
CHX is a potent antiseptic, which is widely
used for chemical plaque control in the oral
cavity in concentration of 0.1% to 0.2%,37
while the concentration of root canal irrigat-
ing solutions usually found in the endodon-
tic literature is 2%.38 This has been found to
be more effective in the least amount of time
when compared with other concentrations of
chlorhexidine ranging from 0.002% to 2%.39
CHX permeates the microbial cell wall or
outer membrane and attacks the bacterial
cytoplasmic or inner membrane or the yeast
plasma membrane.5 However, similar to other
endodontic disinfecting agents, the activity
of CHX depends on the pH and is also greatly
reduced in the presence of organic matter.
CHX cannot be advocated as the main irrig-
ant in standard endodontic cases because it is
unable to dissolve necrotic tissue remnants8
and remove biofilm and it is less effective
on gram-negative than gram-positive bacte-
ria.35,40 It is only because of these differences
6 COMPENDIUM EBOOK SERIES December 2017
ROOT CANAL IRRIGANTS
that CHX cannot replace NaOCl as the gold
standard of root canal irrigants. Direct contact
between NaOCl and CHX should be avoided,
otherwise red CHX crystals will precipitate
immediately (para-chloroaniline, which is
known to be carcinogenic). It would appear
prudent to minimize their formation by wash-
ing away the remaining NaOCl with alcohol
or EDTA before using CHX.41 Several stud-
ies have compared the antibacterial effect of
NaOCl and 2% CHX against intracanal in-
fection and have shown little or no difference
between their antimicrobial effectiveness.42,43
However, CHX does not cause erosion of
dentin like NaOCl does as a final irrigant af-
ter EDTA, and, therefore, 2% CHX may be
a good choice for maximizing antibacterial
effect at the end of chemomechanical prepara-
tion.38 Some studies have indicated that CHX
gel may be slightly more effective than CHX
liquid, but the possible reasons for differences
are unknown.44
Hydrogen Peroxide (H2O2)
Hydrogen peroxide (H2O2) is a clear, odor-
less liquid and is used in dentistry in varying
concentrations of 1% to 30%.5 For endodontic
treatment, concentration between 3% and 5%
solution is used as an irrigating agent. The an-
timicrobial efficiency and the tissue-dissolv-
ing capacity of H2O2 are poor in comparison
with NaOCl. Combining NaOCl with H2O2
produces a bubbling effect as a result of chemi-
cal reaction and reduces the effectiveness of
NaOCl45 (H2O2 + NaOCl à O2 + H2O + NaCl).
H2O2 Mechanism of Action
It rapidly dissociates into H2O + [O] (water
+ nasant oxygen). On coming in contact with
the tissue enzymes catalase and peroxidase,
the liberated nasant oxygen produces a bac-
tericidal effect, but this effect is transient and
diminishes in the presence of organic debris.
This causes oxidation of a bacterial sulfhydryl
group of enzymes and, thus, interferences
CONTINUING EDUCATION 1
with bacterial metabolism. The rapid release
of nasant oxygen on contact with organic tis-
sue results in effervescence or bubbling action,
which is thought to aid in mechanical debride-
ment by dislodging particles of necrotic tissue
and dentinal debris and floating them to the
surface. H2O2 is highly unstable and easily
decomposed by heat and light, and there is
no scientific evidence indicating that H2O2
is superior to other irrigants.
Ethylenediaminetetracetic
acid (EDTA)
EDTA is a commonly used chelating agent.
It was introduced to dentistry by Nygaard-
Østby in 1957 for cleaning and shaping of ca-
nals. While NaOCl is an excellent irrigating
solution, it cannot dissolve inorganic dentin
materials.12 EDTA complements the action of
NaOCl by chelating calcium ions in dentin and
making instrumentation of root canals easier,
and it is effective at a neutral pH. Removal
of smear layer from the root canal is an im-
portant step in endodontics as it exposes the
bacteria living in the dentinal tubules to be
acted upon by the disinfecting irrigants and,
additionally, allows the endodontic sealer to
penetrate into the dentinal tubules for a more
intimate fit leading to an enhanced sealing of
the canal. The formation of sealer tags into
the dentin provides good adaptation between
the sealer cement and the dentin interface.46
This may further reduce the microleakage that
frequently results from improper obturation
of the root canal.
The effect of EDTA on dentin depends on the
concentration of EDTA solution and the length
of time it is in contact with the dentin. EDTA
as a 17% solution effectively removes the smear
layer by chelating the inorganic components of
the dentin.5,20 It has almost no antibacterial ac-
tivity, is highly biocompatible, can demineral-
ize intertubular dentin, and reduces the surface
hardness of root canal wall dentin.47 Teixeira
et al has showed equally effective smear layer
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ROOT CANAL IRRIGANTS
removal after EDTA irrigation for 1, 3, and 5
minutes.48 Crumpton et al showed efficient
smear layer removal with a final rinse of 1 ml
of 17% EDTA for 1 minute.49 Ultrasonics helped
in efficient smear layer removal from the apical
region of the root canal.50
Prolonged exposure to EDTA may weaken
root dentin51 and thereby increase the risk of
creating a perforation during mechanical root
canal instrumentation. Irrigation of the root
canal using alternative NaOCl and EDTA ap-
pears to be very promising.52 This combina-
tion seems to enhance the tissue-dissolution
capability of NaOCl14,52 and is more efficient in
reducing intraradicular microbes than NaOCl
alone.53 EDTA retains its calcium-complexing
ability when mixed with NaOCl, but EDTA
causes NaOCl to lose its tissue-dissolving ca-
pacity.54 Therefore, EDTA and NaOCl should
be used separately and should never be mixed.55
MTAD (Mixture of Tetracycline,
an Acid, and a Detergent)
Torabinejad et al developed an irrigant that is
a mixture of 3% doxycycline, 4.25% citric acid,
and detergent (Tween 80, 0.5%),56 with a pH
of 2.15. The commercial product is BioPure®
(DENTSPLY Tulsa Dental Specialties). It is
effective in removing the smear layer due to its
low pH, and it showed tissue-dissolving action
as long as the canal was rinsed with NaOCl
during mechanical preparation.57 Recent
protocol recommends an initial irrigation
for 20 minutes with 1.3% NaOCl, followed by
a 5-minute final rinse with MTAD.57 MTAD
works better in the apical third to remove the
smear layer as compared to other root canal ir-
rigants.58 In MTAD preparation, the citric acid
may serve to remove the smear layer, allowing
doxycycline to enter the dentinal tubules and
exert an antibacterial effect.57
MTAD seems to adversely influence the
physical properties of dentin and causes signif-
icant reduction in bond strength of both resin-
based and calcium-hydroxide–based sealers
December 2017 COMPENDIUM EBOOK SERIES 7
 CONTINUING EDUCATION 1
due to precipitate formation.59 Concerns have
been expressed regarding the use of tetracy-
cline (doxycycline) because of possible resis-
tance to the antibiotic and staining of tooth
hard tissue, as demonstrated by exposure to
light in an in-vitro model.60 However, no re-
port of in-vivo staining has been published.
Hydroxyethylidene
Bisphosphonate (HEBP)
Also known as etidronate or etidronic acid
having chelating properties, hydroxyethyli-
dene bisphosphonate (HEBP) has been pro-
posed as a potential alternative to EDTA or
citric acid because this agent shows no short-
term reactivity with NaOCl.61 It is nontoxic
and has been systematically applied to treat
bone diseases.62 Continuous chelation irriga-
tion protocol using 5% NaOCl with 18% HEBP
optimizes bonding quality of epoxy resin seal-
er (eg, AH Plus) to dentin.63
Maleic Acid
Maleic acid is a mild organic acid used as an acid
conditioner in adhesive dentistry.64 Effective
smear layer removal takes place at 5% and 7%
concentration, however at 10% or more it can
result in demineralization and damage to the
root canal wall.65 At 7%, maleic acid has proved
to be more efficient than 17% EDTA in removal
of the smear layer from the apical third of the
root canal system.64 It also produces maximum
surface roughness as compared to 17% EDTA,
which plays an important role in micromechan-
ical bonding of resin sealers. However, further
evaluation is needed regarding the biological
effects and technique of use of maleic acid on
periapical tissues before routine clinical use
can be employed.
Tetraclean
A mixture of doxycycline hyclate, an acid, and
a detergent,56 Tetraclean (Ogna Laboratori
Farmaceutici, Milano, Italy) is similar to
MTAD, but the concentration of antibiotic
8 COMPENDIUM EBOOK SERIES December 2017
ROOT CANAL IRRIGANTS
(doxycycline 50 mg/ml) and the type of deter-
gent (polypropylene glycol) differ from those
of MTAD.66 It is able to eliminate microorgan-
isms and the smear layer in dentinal tubules
of infected root canals with a final 5-minute
rinse and opens up the dentinal tubules. It has
low surface tension allowing better adaptation
of the mixtures to the dentinal walls66 and is
effective against both strictly anaerobic and
facultative anaerobic bacteria.67
Other Natural Root Canal Irrigants
Neem (Azardiracta indica) is a versatile medi-
cal plant that has a wide spectrum of biologi-
cal activity. Its antioxidant and antimicrobial
properties make it a potential agent for root
canal irrigation as an alternative to sodium
hypochlorite.68
Turmeric (Curcuma longa) has anti-inflam-
matory, antioxidant, antibacterial, antifun-
gal, and antiviral activities. It is proven to be
safe as a root canal irrigant, effective against
Enterococcus faecalis.69
Liquorice (Glycyrrhiza glabra) is also used
as a root canal irrigant. Liquorice extract,
either separately or as a liquorice/calcium
hydroxide (Ca[OH]2) mixture, had a potent
bactericidal effect against E. faecalis.70
Noni (Morinda citrofolia) is a traditional me-
dicinal plant that has been used in Polynesia
for more than 2,000 years. It has been proven
to effectively remove smear layer from root
canal walls of instrumented teeth in a man-
ner similar to that of NaOCl in conjunction
with EDTA.71
Conclusion
Irrigation plays a vital role in successful end-
odontic treatment. Available literature and
studies demonstrate advantages and limita-
tions of each irrigant under consideration, and
none of them completely satisfy the require-
ments of the ideal root canal irrigant. Although
NaOCl is the most significant irrigating solu-
tion, no single irrigant can accomplish all the
CONTINUING EDUCATION 1
tasks required by irrigation. Understanding
the mode of action of various available and
commonly used solutions is important for
optimal irrigation. New developments in the
composition of the irrigating solutions will
help to advance safe and effective irrigation.
ABOUT THE AUTHORS
Amit Jena, MDS
Reader, Department of Conservative Dentistry &
Endodontics, Institute of Dental Sciences, Siksha ‘O’
Anusandhan University, Odisha, India
Sanjit Kumar Sahoo, MDS
Post-Graduate Student, Reader, Department of Conservative
Dentistry & Endodontics, Institute of Dental Sciences, Siksha
‘O’ Anusandhan University, Odisha, India
Shashirekha Govind, MDS
Reader, Department of Conservative Dentistry &
Endodontics, Institute of Dental Sciences, Siksha ‘O’
Anusandhan University, Odisha, India
Queries to the authors regarding this course may be submit-
ted to authorqueries@aegiscomm.com.
REFERENCES
1. Sadr Lahijani MS, Raoof Kateb HR, Heady R,
Yazdani D. The effect of German chamomile (Mar-
ticaria recutitia L.) extract and tea tree (Melaleuca
alternifolia L.) oil used as irrigants on removal
of smear layer: a scanning electron microscopy
study. Int Endod J. 2006;39(3):190-195.
2. Langeland K. Tissue response to dental caries.
Endod Dent Traumatol. 1987;3(4):149-171.
3. Spangberg L, Engstrom B, Langeland K. Bio-
logical effect of dental materials. 3. Toxicity and an-
timicrobial effect of endodontic antiseptics in vitro.
Oral Surg Oral Med Oral Pathol. 1973;36(6):856-871.
4. McKenna SM, Davies KJ. The inhibition of bacte-
rial growth by hypochlorous acid. Possible role in
the bactericidal activity of phagocytes. Biochem J.
1988;254(3):685-692.
5. Haapasalo M, Endal U, Zandi H, Coli J. Eradi-
cation of endodontic infection by instrumenta-
tion and irrigation solutions. Endodontic Topics.
2005;10(1):77-102.
6. McDonnell G, Russell AD. Antiseptics and
disinfectants: activity, action, and resistance. Clin
Microbiol Rev. 1999;12(1):147-179.
7. Zehnder M, Kosicki D, Luder H, et al. Tissue
dissolving capacity and antibacterial effect of
buffered and unbuffered hypochlorite solutions.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
www.compendiumlive.com
ROOT CANAL IRRIGANTS
2002;94(6):756-762.
8. Naenni N, Thoma K, Zehnder M. Soft tissue dis-
solution capacity of currently used and potential
endodontic irrigants. J Endod. 2004;30(11):785-787.
9. Gutierrez JH, Jofre A, Villena F. Scanning
electron microscope study on the action of
endodontic irrigants on bacterial invading the
dentinal tubules. Oral Surg Oral Med Oral Pathol.
1990;69(4):491-501.
10. Sarbinoff JA, O’Leary TJ, Miller CH. The
comparative effectiveness of various agents in
detoxifying diseased root surfaces. J Periodontol.
1983;54(2):77-80.
11. Buttler TK, Crawford JJ. The detoxifying effect
of varying concentration of sodium hypochlorite
on endotoxins. J Endod. 1982;8(2):59-66.
12. McComb D, Smith DC, Beagrie GS. The results
of in vivo endodontic chemomechanical instru-
mentation–a scanning electron microscopy study.
J Br Endod Soc. 1976;9(1):11-18.
13. Pashley EL, Birdsong, NL, Bowmen K, Pashley
DH. Cytotoxic effects of NaOCl on vital tissue.
J Endod. 1985;11(12):525-528.
14. Niu W, Yoshioka T, Kobayashi C, Suda H. A
scanning electron microscopic study of dentinal
erosion by final irrigation with EDTA and NaOCl
solutions. Int Endod J. 2002;35(11):934-939.
15. Haapasalo M, Shen Y, Qian W, Gao Y. Ir-
rigation in endodontics. Dent Clin North Am.
2010;54(2):291-312.
16. Sjogren U, Figdor S, Persson S, Sundqvist G.
Influence of infection at the time of root fill-
ing on the outcome of endodontic treatment
of teeth with apical periodontics. Int Endod J.
1997;30(5):297-306.
17. Baker NA, Eleazer PD, Averbach RE, Seltzer
S. Scanning electron microscopic study on the
efficacy of various irrigating solutions. J Endod.
1975;1(4):127-135.
18. Sedgley C, Applegate B, Nagel A, Hall D.
Real-time imaging and quantification of biolumi-
nescent bacteria in root canals in vitro. J Endod.
2004;30(12):893-898.
19. Peters O A. Current challenges and concepts
in the preparation of root canal systems: a review.
J Endod. 2004;30(8):559-567.
20. Cunningham WT, Balekjian AY. Effect of tem-
perature on collagen-dissolving ability of sodium
hypochlorite endodontic irrigant. Oral Surg Oral
Med Oral Pathol. 1980;49(2):175-177.
21. Sirtes G, Waltimo T, Schaetzle M, Zehnder
M. The effects of temperature on sodium hy-
pochlorite short-term stability, pulp dissolution
capacity, and antimicrobial efficacy. J Endod.
2005;31(9):669-671.
22. Cunningham WT, Joseph SW. Effect of tem-
perature on the bactericidal action of sodium
December 2017 COMPENDIUM EBOOK SERIES 9
 CONTINUING EDUCATION 1
hypochlorite endodontic irrigant. Oral Surg Oral
Med Oral Pathol. 1980;50(6):569-571.
23. Abou-Rass M, Piccinino MV. The effectiveness
of four clinical irrigation methods on the removal
of root canal debris. Oral Surg Oral Med Oral
Pathol. 1982;54(3):323-328.
24. Martin H. Ultrasonic disinfection of the
root canal. Oral Surg Oral Med Oral Pathol.
1976;42(1):92-99.
25. Mayer BE, Peters OA, Barbakow F. Effects of ro-
tary instruments and ultrasonic irrigation on debris
and smear layer scores: a scanning electron micro-
scopic study. Int Endod J. 2002;35(7):582-589.
26. Piskin B, Turkun M. Stability of various sodium
hypochlorite solutions. J Endod. 1995;21(5):253-255.
27. Schafer E. Irrigation of the root canal. Endo.
2007;1(1):11-27.
28. Cavalleri G, Cantatore G, Costa A, et al. The
corrosive effects of sodium hypochlorite on nick-
el-titanium endodontic instruments: assessment
by digital scanning microscope. Minerva Stomatol.
2009;58(5):225-231.
29. Morris MD, Lee KW, Agee KA, et al. Effect
of sodium hypochlorite and RC-prep on bond
strengths of resin cement on endodontic surfaces.
J Endod. 2001;27(12):753-757.
30. Ari H, Yasar E, Belli S. Effects of NaOCl on
bond strengths of resin cements to root canal
dentin. J Endod. 2003;29(4):248-251.
31. Lai SC, Mak YF, Cheung GS, et al. Reversal of
compromised bonding to oxidized etched dentin.
J Dent Res. 2001;80(10):1919-1924.
32. Marchesan MA, Pasternak Junior B, Afonso
MM, et al. Chemical analysis of the flocculate
formed by the association of sodium hypochlorite
and chlorhexidine. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2007;103(5):103-105.
33. Bui TB, Baumgartner JC, Mitchell JC. Evalua-
tion of the interaction between sodium hypochlo-
rite and chlorhexidine gluconate and its effect on
root dentin. J Endod. 2008;34(2):181-185.
34. Hulsmann M, Hahn W. Complications during
root canal irrigation–literature review and case
reports. Int Endod J. 2000;33(3):186-193.
35. Davies GE, Francis J, Martin AR, et al. 1:6-Di-4’-
chlorophenyldiguanidohexane (hibitane); labora-
tory investigation of a new antibacterial agent
of high potency. Br J Pharmacol Chemother.
1954;9(2):192-196.
36. Foulkes DM. Some toxicological observa-
tions on chlorhexidine. J Periodontal Res Suppl.
1973;12:55-60.
37. Addy M, Moran JM. Clinical indications for
the use of chemical adjuncts to plaque control:
chlorhexidine formulations. Periodontol 2000.
1997;15:52-54.
38. Zamany A, Safavi K, Spångberg LS. The effect
of chlorhexidine as an endodontic disinfectant.
10 COMPENDIUM EBOOK SERIES December 2017
ROOT CANAL IRRIGANTS
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2003;96(5):578-581.
39. Schäfer E, Bössmann K. Antimicrobial efficacy
of chlorhexidine and two calcium hydroxide for-
mulations against Enterococcus faecalis. J Endod.
2005;31(1):53-56.
40. Hennessey TS. Some antibacterial proper-
ties of chlorhexidine. J Periodontal Res Suppl.
1973;12:61-67.
41. Basrani BR, Manek S, Sodhi RN, et al. Interac-
tion between sodium hypochlorite and chlorhexi-
dine gluconate. J Endod. 2007;33(8):966-969.
42. Vahdaty A, Pitt Ford TR, Wilson RF. Efficacy
of chlorhexidine in disinfecting dentinal tubules in
vitro. Endod Dent Traumatol. 1993;9(6):243-248.
43. Jeansonne MJ, White RR. A comparison of
2.0% chlorhexidine gluconate and 5.25% sodium
hypochlorite as antimicrobial endodontic irrigants.
J Endod. 1994;20(6):276-278.
44. Ferraz CC, Gomes BP, Zaia AA, et al. In vitro
assessment of the antimicrobial action and the
mechanical ability of chlorhexidine gel as an end-
odontic irrigant. J Endod. 2001;27(7):452-455.
45. Heling I, Chandler NP. Antimicrobial effect of
irrigant combinations within dentinal tubules. Int
Endod J. 1998;31(1):8-14.
46. De-Deus G, Reis C, Di Giorgi K, et al. Interfacial
adaptation of the Epiphany self-adhesive sealer to
root dentin. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2011;111(3):381-386.
47. Hulsmann M, Heckendorff M, Lennon A. Che-
lating agents in root canal treatment: mode of
action and indications for their use. Int Endod J.
2003;36(12):810-830.
48. Teixeira CS, Felippe MC, Felippe WT. The ef-
fect of application time of EDTA and NaOCl on
intracanal smear layer removal: an SEM analysis.
Int Endod J. 2005;38(5):285-290.
49. Crumpton BJ, Goodell GG, McClanahan SB.
Effects on smear layer and debris removal with
varying volumes of 17% REDTA after rotary instru-
mentation. J Endod. 2005;31(7):536-538.
50. Kuah HG, Lui JN, Tseng PS, Chen NN. The
effect of EDTA with and without ultrason-
ics on removal of the smear layer. J Endod.
2009;35(3):393-396.
51. Calt S, Serper A. Time dependent ef-
fects of EDTA on dentin structures. J Endod.
2002;28(1):17-19.
52. Yamashita JC, Tanomaru Filho M, Leonard MR,
et al. Scanning electron microscopic study of the
cleaning ability of chlorhexidine as a root-canal
irrigant. Int Endod J. 2003;36(6):391-394.
53. Bystrom A, Sundqvist G. The antibacterial action
of sodium hypochlorite and EDTA in 60 cases of
endodontic therapy. Int Endod J. 1985;18(1):35-40.
54. Gutmann JL, Saunders WP, Nguyen L, et
al. Ultrasonic root-end preparation. Part 1. SEM
CONTINUING EDUCATION 1
analysis. Int Endod J. 1994;27(6):318-324.
55. Grawehr M, Sener B, Waltimo T, Zehnder M.
Interaction of ethylenediamine tetraacetic acid
with sodium hypochlorite in aqueous solutions. Int
Endod J. 2003;36(6):411-417.
56. Torabinejad M, Khademi AA, Babagoli J, et al.
A new solution for the removal of smear layer.
J Endod. 2003;29(3):170-175.
57. Torabinejad M, Cho Y, Khademi AA, et al. The
effect of various concentrations of sodium hy-
pochlorite on the ability of MTAD to remove the
smear layer. J Endod. 2003;29(4):233-239.
58. Paul ML, Mazumdar D, Niyogi A, Baranwal AK.
Comparative evaluation of efficacy of different
irrigants including MTAD under SEM. J Conserv
Dent. 2013;16(4):336-341.
59. Gopikrishna V, Venkateshbabu N, Krithikadatta
J, Kandaswamy D. Evaluation of the effect of
MTAD in comparison with EDTA when employed
as the final rinse on the shear bond strength of
three endodontic sealers to dentine. Aust Endod J.
2010;37(1):12-17.
60. Tay FR, Mazzoni A, Pashley DH, et al. Potential
iatrogenic tetracycline staining of endodontically
treated teeth via NaOCl/MTAD irrigation: a pre-
liminary report. J Endod. 2006;32(4):354-358.
61. Zehnder M, Schmidlin P, Sener B, Waltimo T.
Chelation in root canal therapy reconsidered.
J Endod. 2005;31(11):817-820.
62. Russell RG, Rogers MJ. Bisphosphonates:
From the laboratory to the clinic and back again.
Bone. 1999;25(1):97-106.
63. Neelakantan P, Varughese AA, Sharma S, et
al. Continuous chelation irrigation improves the
adhesion of epoxy resin-based root canal sealer
to root dentine. Int Endod J. 2012;45(12):1097-1102.
www.compendiumlive.com
ROOT CANAL IRRIGANTS
64. Ballal NV, Kandian S, Mala K, et al. Comparison
of the efficacy of maleic acid and ethylenediami-
netetraacetic acid in smear layer removal from in-
strumented human root canal: a scanning electron
microscopic study. J Endod. 2009;35(11):1573-1576.
65. Prabhu SG, Rahim N, Bhat KS, Mathew J.
Comparison of removal of endodontic smear
layer using NaOCl, EDTA, and different concentra-
tions of Maleic acid–A SEM study. Endodontol-
ogy.2003;15:20-25.
66. Giardino L, Ambu E, Becce C, et al. Surface
tension comparison of four common root canal
irrigants and two new irrigants containing antibi-
otic. J Endod. 2006;32(11):1091-1093.
67. Giardino L, Savoldi E, Ambu E, et al. Antimi-
crobial effect of MTAD, Tetraclean, Cloreximid and
sodium hypochlorite on three common endodon-
tic pathogens. Indian J Dent Res. 2009;20(3):391.
68. Sudhakar B, Nivedhitha MS, Kumar A, et al.
Comparative evaluation of cytotoxity of endodon-
tic irrigants–chlorhexidine, sodium hypochlorite
and Neem extract. Journal of Pharmacy Research.
2012;5(3):1273-1275.
69. Vinothkumar TS, Rubin MI, Balaji L, Kandas-
wamy D. In vitro evaluation of five different herbal
extracts as an antimicrobial endodontic irrigant
using real time quantitative polymerase chain
reaction. J Conserv Dent. 2013;16(2):167-170.
70. Badr AE, Omar N, Badria FA. A laboratory
evaluation of the antibacterial and cytotoxic ef-
fect of Liquorice when used as root canal medica-
ment. Int Endod J. 2011;44(1):51-58.
71. Murray PE, Farber RM, Namerow KN, et al.
Evaluation of Morinda citrofolia as an endodontic
irrigant. J Endod. 2008;34(1):66-7022.
December 2017 COMPENDIUM EBOOK SERIES 11
 CONTINUING EDUCATION 1 QUIZ 2 Hours CE Credit

Root Canal Irrigants: A Review of

Their Interactions, Benefits, and Limitations
Amit Jena, MDS; Sanjit Kumar Sahoo, MDS; and Shashirekha Govind, MDS

THIS COURSE IS AVAILABLE ONLINE AT: COMPENDIUMLIVE.COM/GO/UPDATESENDO1.

ENTER PROMO CODE: UPEND1

1. 
Infection of the root canal spaces occurs most 6. A rise in temperature by 25°C increased NaOCl
frequently as a sequela to: efficacy by a factor of:
A. a failed implant. A. 20.
B. temporomandibular joint dysfunction. B. 45.
C. a profound caries lesion. C. 100.
D. excessive bruxism. D. 200.

2. Complementary to instrumentation for 7. 

For chemical plaque control in the oral cavity
facilitating the removal of pulp tissue and/or chlorhexidine digluconate (CHX) is widely used
microorganisms is: in concentration of:
A. irrigation. A. 0.1% to 0.2%.
B. scaling and root planing. B. 0.5% to 5.25%.
C. water flossing. C. 2%.
D. consistent toothbrushing. D. 3% to 5%.

3. A root canal irrigant should facilitate: 8. What clear, odorless liquid is used as an
A. dentin removal but not weaken the irrigating agent for endodontic treatment in
tooth structure. concentration between 3% and 5% solution?
B. dentin removal while diminishing A. chlorhexidine digluconate (CHX)
tooth structure. B. ethylenediaminetetracetic acid (EDTA)
C. tooth structure removal. C. maleic acid
D. thickening of the smear layer. D. hydrogen peroxide (H2O2)

4. In endodontic therapy, sodium hypochlorite 9. The effect of EDTA on dentin depends on the
(NaOCl) solutions are used in concentrations concentration of EDTA solution and the:
that vary from: A. temperature at which it is used.
A. 0.002% to 2%. B. surface hardness of the dentin.
B. 0.5% to 5.25%. C. length of time the EDTA is in contact with
C. 5.25% to 25%. the dentin.
D. 7% to 9%. D. amount of time the cleaning file is in the canal.

5. The dissolving capacity of NaOCl is significantly 10. At 5% and 7% concentration of maleic acid, what
better than all other commonly used irrigants takes place?
but is dependent on: A. resistance to antibacterial activity
A. the proteolytic action of concentrated B. staining of tooth hard tissue
hypochlorite. C. demineralization and damage to the root
B. the thickness of the canal wall dentin. canal wall
C. activation of lipopolysaccharides. D. effective smear layer removal
D. the concentration of the solution.

Course is valid from 12/1/2017 to 12/31/2020. Participants

must attain a score of 70% on each quiz to receive credit. Par-
ticipants receiving a failing grade on any exam will be notified
and permitted to take one re-examination. Participants will
receive an annual report documenting their accumulated
credits, and are urged to contact their own state registry
boards for special CE requirements.
AEGIS Publications, LLC, is an ADA CERP Recognized
Provider. ADA CERP is a service of the American Dental Approval does not imply acceptance
Association to assist dental professionals in identifying quality
by a state or provisional board of
providers of continuing dental education. ADA CERP does not
approve or endorse individual courses or instructors, nor does
dentistry or AGD endorsement. The
current term of approval extends from
it imply acceptance of credit hours by boards of dentistry.
1/1/2017 to 12/31/2022.
Concerns or complaints about a CE provider may be directed
to the provider or to ADA CERP at www.ada.org/cerp. Provider #: 209722.

12 COMPENDIUM EBOOK SERIES December 2017

CONTINUING EDUCATION 2 ENDODONTIC MATERIALS

Bioactive Materials in
Endodontics: An Evolving
Component of Clinical Dentistry
Satyajit Mohapatra, MDS; Swadheena Patro, MDS; and Sumita Mishra, MDS

ABSTRACT: Achieving biocompatibility in a material requires an interdisciplinary

approach that involves a sound knowledge of materials science, bioengineering, and
biotechnology. The host microbial–material response is also critical. Endodontic
treatment is a delicate procedure that must be planned and executed properly. Despite
major advances in endodontic therapy in recent decades, clinicians are confronted
with a complex root canal anatomy and a wide selection of endodontic filling materials
that, in turn, may not be well tolerated by the periapical tissues and may evoke an
immune reaction. This article discusses published reports of various bioactive
materials that are used in endodontic therapy, including calcium hydroxide, mineral
trioxide aggregate, a bioactive dentin substrate, calcium phosphate ceramics, and
calcium phosphate cements.

LEARNING OBJECTIVES

• Explain the findings on various • Identify the uses for current • Discuss the potential clinical
bioactive materials bioactive materials for applications for these
endodontic and restorative products
care

E
ndodontic therapy is performed
to prevent or treat apical periodon-
titis and consists of the total or
partial removal of dental pulp. To
a certain extent, vital functioning
pulp serves as the most efficient barrier against
bacterial invasion.1 However, numerous studies
have proven that direct pulp capping in cariously
exposed teeth provides unpredictable results and
is less successful than complete pulpectomy.2
This could be related to remnant bacteria in
surrounding dentin despite excavation of clini-
cal caries and the inflammatory response to the
DISCLOSURE: The authors had no disclosures to report.
carious exposure extending to the pulp tissue.3 In
addition, it may be related to an inadequate long-
term seal resulting in microorganism microleak-
age or to materials that fail to achieve pulp repair
and dentin bridge formation.4 The success of pulp
capping therapy depends on complete disinfec-
tion through chemomechanical debridement of
the pathological or necrotic pulp tissue, followed
by hermetically sealing the root canal system
from the oral and periapical environment.
Despite the progress made in improving the
performance of root canal preparation and fill-
ing techniques, clinicians are still confronted with

www.compendiumlive.com December 2017 COMPENDIUM EBOOK SERIES 13

 CONTINUING EDUCATION 2
two problems. The first issue is the complexity of
the pulp root canal and its ramifications, which
creates major difficulties for complete disinfec-
tion, shaping, and filling to prevent bacterial
infiltration and ingress. The other problem is
that root canal filling materials do not meet all
the requirements of an ideal material, including
adhesion to dentin, maintaining a sufficient seal,
insolubility in tissue fluids, dimensional stability,
resorbability, radiopacity, antibacterial activity,
and biocompatibility.5 In addition, while sealers
and filling materials used for endodontic practice
have previously proven their biocompatibility in
several in vitro and in vivo tests, controversy still
remains regarding the acceptable biocompatibil-
ity of primary endodontic filling materials, po-
tentially hindering the healing process in cases
involving extrusion beyond the canal.6
In recent decades, new biomaterials have
been used in endodontic therapies, particularly
mineral trioxide aggregate (MTA)- and calcium
phosphate-based materials. These materials
promote pulpal and periapical healing because
of their biocompatibility and bioactive proper-
ties, thereby improving the prognosis for end-
odontic treatments. The question that needs to
be addressed has to do with determining the kind
of biomaterials and the conditioning that can
be used going forward. Progress in biomedical
research has provided new directions for the
design of biologically effective pulp therapies.
Thus, this article reviews the various bioactive
materials used in endodontics.
Methods
The search strategy followed the indications of
the National Health Service’s Centre for Reviews
and Dissemination in the United Kingdom, and
researchers used the Medline database for ar-
ticles. The key MeSH terms used were: bioac-
tive and bioactive materials in endodontics.
The search was later expanded to gather more
information by including the following databas-
es: Scopus, EBSCOHost, Scirus, and Cochrane.
The keywords used were: bioactive materials
14 COMPENDIUM EBOOK SERIES December 2017
ENDODONTIC MATERIALS
and bioactive materials in endodontics. Selected
article references were reviewed to extend the
search for relevant articles.
Biocompatibility of Current
Endodontic Filling Materials
Biocompatibility tests have shown that all of the
currently used filling materials, including gutta
percha (GP), cause local adverse effects on vital
tissues.7 GP has been the most widely used root
canal filling material because findings from ani-
mal studies showed it to be well tolerated and the
formation of a fibrous tissue capsule surround-
ing pieces of GP has been reported.8 However,
the inertness of GP has been an issue, with in
vivo tissue experiments showing cytotoxic reac-
tions being caused to varying extents depending
on the size, surface characteristics, formulation,
and type of GP. Fine particles of GP (eg, those
resulting from thermocompaction) can cause an
intense, localized tissue response that may be a
significant factor in the impairment of healing
of periapical lesions in the case of overfilling.9
Certain endodontic sealers can cause local
and systemic adverse effects. Numerous com-
monly used root canals sealers, such as epoxy
resin-based, calcium hydroxide-based, and
zinc oxide–eugenol-based sealers, possess
a marked cytotoxic and tissue-irritating po-
tency, notably for periodontal ligament cells.10
Eugenol, zinc, or formaldehyde products of
root canal sealers have significant potential
toxicity for periapical tissues.11,11A
In addition, root canal sealers dissolve when
exposed to an aqueous environment for extended
periods, possibly causing moderate or severe cy-
totoxic reactions and contributing to endodontic
treatment failure. Sealers even induce necrosis of
bone or cementum.12 Histologic investigations on
monkeys have demonstrated that root canal seal-
ers can induce mild-to-severe periapical inflam-
mation, especially when teeth were overfilled.13
Mutagenic and genotoxic effects have also
been observed with sealers releasing formal-
dehyde or generating this substance during
CONTINUING EDUCATION 2
their setting reaction, as well as with sealers
containing bisphenol-A-diglycidylether or its
derivatives.14 The use of epoxy resin-based seal-
ers induced the highest level of DNA damage.15
Furthermore, the obvious carcinogenicity of the
formaldehyde-releasing and epoxy resin-based
root canal sealers on human osteoblastic cells
should be taken into consideration.
Although the presence of pathogens in the root
canal system and preoperative periradicular le-
sions are the primary causes of endodontic fail-
ure, it is widely assumed that the tissue response
to root canal filling materials becomes signifi-
cant in the event of overfilling and may influence
the outcome of endodontic treatment. Thus, use
of materials with potential risks for cytotoxicity,
genotoxicity, mutagenicity, or carcinogenicity
should be avoided in practice because safer al-
ternatives are available.
Calcium Hydroxide
Calcium hydroxide, or Ca(OH)2, has good anti-
bacterial properties. It has an alkaline pH (a level
of approximately 12) that helps reduce osteo-
clastic activity and induce bone formation. The
alkaline pH level causes activation of alkaline
phosphatise enzyme that induces osteoblastic
activity.16 However, calcium hydroxide also acts
by other mechanisms.17 When used as a pulp cap-
ping agent, it induces dentin bridge formation.18
The alkaline pH concentration may be respon-
sible for the formation of dentin bridge.19
Pulpal fibroblast-like cells differentiate and may
lead to dentinogenesis. When placed in contact
with connective tissue, these cells promote the
formation of a cementoid barrier. In vitro stud-
ies have demonstrated the fibroblast-like cells,
when in direct contact with the calcium hydrox-
ide, exhibit dramatic alteration in the morphol-
ogy, growth rate, protein synthesis, and alkaline
phosphatase activity.20 However, because calcium
hydroxide is soluble and degrades with time, it
may not provide a permanent long-term bacte-
riometic seal if the restoration eventually fails.21
In other endodontic procedures, calcium hy-
www.compendiumlive.com
ENDODONTIC MATERIALS
droxide allows clinical control of infection and
may improve the prognosis for apical periodon-
titis. Some authors report a success rate of ap-
proximately 81% after 5 years of treatment with
the use of calcium hydroxide in infected teeth.22
However, the main disadvantage of calcium hy-
droxide is that it must be replaced many times in
apexification and foraminal closure, which are
consequently long-term procedures, requiring
6 to 18 months to obtain an apical barrier,23 and
a reduction in microhardness of root dentin has
been shown after applying long-term calcium
hydroxide therapy.
Calcium Silicate-Based
Bioactive Materials
Mineral Trioxide Aggregate
MTA was developed by Torabinejad and White
in the early 1990s as a potential root-end filling
material or for use as a repair material for lat-
eral root perforations.24 It is composed mainly
of tricalcium silicate, dicalcium silicate, trical-
cium aluminate, and tetracalcium aluminofer-
rite. Initially available only in gray, white MTA
was subsequently introduced due to the discol-
oration potential associated with gray MTA.25
White MTA lacks the aluminoferrite phase that
imparts grayness.26
Nontoxic and biocompatible, the material
induces the formation of mineralized tissues.27
The mechanism of formation of hard tissues is
the calcium oxides of MTA reacting with tissue
fluids to form calcium hydroxide. Some authors
believe the high alkaline nature of MTA is mainly
due to the calcium hydroxide that is formed and
is also responsible for its biological properties.28
Antibacterial and antifungal activities have also
been studied.29 The antibacterial effect of MTA
was less than that of calcium hydroxide. Its seal-
ing ability has been extensively evaluated using
various methods and was found to be superior
to conventional retrograde filling materials.30
Studies of MTA as an apexification mate-
rial have found it to provide a good apical seal.
A 5-mm apical barrier of MTA followed by GP
December 2017 COMPENDIUM EBOOK SERIES 15
 CONTINUING EDUCATION 2
condensation after 24 hours has been advocated.31
MTA has shown to resist compaction forces of
GP condensation. The sealing ability, biocom-
patibility, and dentinogenic activity of MTA are
attributed to the production of an adherent in-
terfacial layer that resembles hydroxyapatite in
composition. It was concluded that calcium ions
released from MTA react with the phosphate ions
in tissue fluid, yielding hydroxyapatite.32 MTA
supports cellular adhesion and cellular growth.33
There is an increase of osteoblastic activity mark-
ers (interleukin [IL]-1β, IL-1β, osteocalcin, and
alkaline phosphatase) in contact with MTA.34 A
recent study investigating the effects of MTA on
cementoblast growth and osteocalcin production
in tissue culture has shown that this biomaterial
could be considered cementoconductive.35
Bioactive Dentin Substitute
A calcium silicate-based product specifically de-
signed as a dentin replacement material became
commercially available in 2009. This bioactive
dentin substrate has a wide range of applications,
including endodontic repair (root perforations,
apexification, resorptive lesions, and retrograde
filling material in endodontic surgery) and pulp
capping and as a dentin replacement material in re-
storative dentistry. The material is formulated us-
ing MTA-based cement technology and improves
on some properties of these types of cements, such
as physical qualities and handling. With potential
for managing a deep carious cavity in operative
dentistry whether or not the pulp is exposed, the
material is able to stimulate tissue regeneration
and has good pulp response. Its dentin-like me-
chanical properties have a beneficial effect on liv-
ing cells and act in a biocompatible manner.36
Consisting mainly of tricalcium silicate, dical-
cium silicate, calcium carbonate, calcium oxide,
iron oxide, and zirconium dioxide as a radiopaci-
fier, the liquid portion of the product contains
calcium chloride and a hydrosoluble polymer.
Once mixed, it has a setting time of 12 minutes.
The material induces mineralization in the
form of osteodentine by expressing markers of
16 COMPENDIUM EBOOK SERIES December 2017
ENDODONTIC MATERIALS
odontoblasts and increases transforming growth
factor (TGF)-beta 1 secretion from pulpal cells,
enabling early mineralization. During the setting
of the cement, calcium hydroxide is formed. Due
to its high pH level, calcium hydroxide causes
irritation at the area of exposure. This zone
of coagulation necrosis has been suggested to
cause division and migration of precursor cells
to the substrate surface—the addition and cy-
todifferentiation into odontoblast-like cells.37
Therefore, this material induces apposition of
reactionary dentin by odontoblast stimulation
and reparative dentin by cell differentiation.
Biocompatibility has been investigated by
various authors. Laurent et al tested the calcium
silicate-based material to evaluate its genotox-
icity, cytoxicity, and effects on the target cell’s
specific function. The study concluded that it is
biocompatible. Also, the material was not found
to affect the specific functions of the target cells
and, thus, could safely be used. Further, it does
not impact human pulp fibroblast functions, ex-
pression of alpha type 1 collagen, dentine sialo-
protein, and Nestin.36,38
The marginal adaptation of the bioactive
substrate has been observed to be microme-
chanical. The high pH level causes organic tis-
sues to dissolve from the dentin tubule. The
alkaline environment at the boundary area of
contact between the material and hard tooth
substance opens a path through which the
dentin substitute mass can enter the exposed
opening of the dentin canaliculi.39 The mate-
rial is used as a pulp capping agent, inducing
the formation of a dentin bridge. Histologic
studies comparing the dentin bridge formed
between MTA and the bioactive substrate have
concluded that the material induces complete
dentin bridge without any evidence of pulpal
inflammation.40 Due to excellent sealing prop-
erties and bioactivity, the bioactive substrate
material has also been advocated as a root-
end filling material or for root perforations.41
Other clinical applications include apexifica-
tion and primary tooth pulpotomy.
CONTINUING EDUCATION 2
Calcium Phosphate Biomaterials
Calcium phosphate biomaterials are biocom-
patible and nontoxic and can induce mineral-
ized tissue formation. Partial dissolution of
calcium phosphate ceramics leads to precipi-
tation of apatite microcrystals in the center
and on the surfaces of the biomaterial. These
biomaterials also sustain cellular degrada-
tions (phagocytosis and osteoclasis) and are
replaced by new hard, calcified tissue. The
biomaterial can favor osteoconduction by its
porosity, allowing colonization of either bone
or the dental pulp implantation site by osseous
cells such as osteocytes and osteoblasts.
Calcium phosphate biomaterials act as scaf-
fold for the formation of new mineralized tissue.
They are able to create a tight bond with miner-
alized tissues, which could serve as an effective
barrier against bacterial leakage in the apical
area and dentin–pulp interface.42
Calcium Phosphate Ceramics
Studies on calcium phosphate ceramics have
identified their bioactivity and sealing abilities.
These materials can be used in pulp capping and
apexification or during endodontic surgery.43
Many in vivo studies explored the use of differ-
ent types of calcium phosphate ceramics in pulp
capping in efforts to induce new dentin forma-
tion without an initial necrotic fibrous layer and
while avoiding pulpal cell alterations usually ob-
served using calcium hydroxide products.
Satisfactory results were reported with hy-
droxyapatite (HA), tricalcium phosphate
(β-TCP), biphasic calcium phosphate (BCP; an
intimate mixture of HA and β-TCP), octacal-
cium phosphate (OCP), and dicalcium phos-
phate dihydrate (DCPD).44,45 HA is ideal as an
inorganic component of calcified tissues. DCPD,
OCP, and β-TCP are able to transform into apa-
tites similar to biologic apatites.46
In vivo studies evaluating the dentinogenic
effect of calcium phosphate ceramics on ani-
mal models reported three types of mineraliza-
tion: dentin bridge formation, dystrophic cal-
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ENDODONTIC MATERIALS
cification, and mineralization. Microparticles
of β-TCP, HA, and BCP are responsible for the
formation of a calcified bridge similar to that
observed with calcium hydroxide, although
success was more frequently obtained with HA
and BCP.47 OCP and DCPD evaluated in vari-
ous animal models caused extensive dystrophic
mineralized tissue in the pulp chamber and also
along the root canal walls. Using macroparticles
of β-TCP, HA, or BCP in animal models, homog-
enous mineralization was observed around the
biomaterials.48
These histologic observations have suggested
calcium phosphate ceramics may be useful for
specific applications in endodontics, including
microparticles of HA, TCP, and BCP for pulp
capping, and macroparticles of HA, OCP, and
DCPD for pulpotomy and apexification.
Calcium Phosphate Cements
The concept of apatitic calcium phosphate ce-
ment (CPC) was first introduced by LeGeros
in 1982. CPCs have been used as bone sub-
stitutes to repair craniofacial defects and
proposed for use in pulp capping, endodontic
sealing, and filling.49,50 New self-setting CPCs
containing calcium oxide (CaO) or calcium
hydroxide have also been developed; these
biomaterials may be an interesting alterna-
tive to calcium hydroxide, which is currently
used in endodontics. A monocalcium phos-
phate-monohydrate–CaO-based cement was
recently proposed for endodontic treatment
with better mechanical properties than calci-
um hydroxide. The setting reaction produced
a mixture of calcium-deficient hydroxyapatite
(CDHA) and calcium hydroxide. The pres-
ence of calcium hydroxide would confer an-
tibacterial properties to this CPC. Similarly,
by mixing DCPD and CaO, a CPC with better
mechanical and physical properties for dental
applications was obtained. This DCPD–CaO-
based cement provided a better seal than the
one obtained using zinc oxide-eugenol cement
with or without a GP point. In addition, this
December 2017 COMPENDIUM EBOOK SERIES 17
 CONTINUING EDUCATION 2
cement also presented antibacterial effects
due to the presence of calcium hydroxide.51
Another composite material consisting of
MTA with a CPC matrix was also developed
as a root-end filling material to combine the
qualities, biological properties, and sealing
ability of each biomaterial and to improve its
manipulation characteristics.52 Its chemical
properties and biocompatibility are similar to
those of MTA. In addition, chitosan-based ce-
ments, which are nonrigid cellulosic cements,
were evaluated and the preliminary results on
their bioactivity and biocompatibility showed
that they could be promising for various dental
applications such as endodontics.53
The relatively small size and lack of accessibil-
ity of the various endodontic sites have neces-
sitated the development of injectable forms of
calcium phosphate cement. However, its thick
consistency is not suitable for injection pur-
poses, and thus numerous materials have been
added to improve its rheological properties.
Experimental studies have been conducted with
glycerine,54 silicon gel,55 polyethylene glycol, liq-
uid paraffin, glycerol56 cellulose, and titanium
dioxide.57 To promote periapical tissue healing,
the addition of another gel agent, chondroitin
sulfate, was also proposed in CPC formulation.
Other components, such as dispersants, bind-
ers, plasticizers, or drugs, can be incorporated
to modify their biological properties and in-
jectability. Several in vivo studies58 were made
with CPC used as a sealer in association with
GP. CPC was more biocompatible and induced a
less inflammatory reaction compared with zinc
oxide-eugenol sealer.
In endodontics, a composite material of calci-
um phosphate and collagenic gel was first tested
on monkeys in 1977 and 1978 in apexification,
pulpotomy, and partial pulpectomy to induce
the physiological canal space closure.58,59 This
composite gel was shown to promote pulp cal-
cification. Nontoxic and biocompatible, it was
resorbed and replaced by mineralized tissues
that looked like dentin or cementum.
18 COMPENDIUM EBOOK SERIES December 2017
ENDODONTIC MATERIALS
Injectable Bone Substitutes
Injectable bone substitute (IBS) material is a ce-
ramic consisting of biphasic calcium phosphate
in a matrix of hydroxypropylmethyl cellulose.60
The main feature of this injectable biomaterial is
the mineral component with various HA:β-TCP
ratios, making it possible to control its kinetics of
dissolution and precipitation, and, subsequently,
the bioactivity of the bone substitute.61 CPCs
provide dense biomaterials with irregular mi-
croporosity, whereas macroporosity is known
to be an essential factor for homogeneous and
early bone colonization.62
In endodontics, the difficulty in injecting a ce-
ramic through a thin needle relates to the water
used as the liquid-phase carrier. However, in-
jectable calcium phosphate biomaterials would
be able to pass through thin needles and dental
root canals without alteration or demixing of the
phases. Water or liquid phases without viscous
consistency show Newtonian properties, and an
aqueous polymer solution is a better carrier for
mineral granules. Apparent viscosity measure-
ments and extrusion tests have indicated that
macromolecules are most suitable for this pur-
pose. An injectable composite IBS (80 μm to 200
μm) consisting of a 2% aqueous cellulose ether
solution and biphasic calcium phosphate gran-
ules of 80 μm to 200 μm have been tested. The cel-
lulosic gels are pseudoplastic, and their viscosity
decreases with the shearing during the extrusion
from the syringe and increases after injection. To
develop an injectable composite for endodontics,
small calcium phosphate granules are preferable
for injection in a narrow root canal. Few studies
have been conducted on the role of particle size
of calcium phosphate ceramic on wound healing
and calcified tissue ingrowth, but the few available
have shown conflicting results.63
In vivo studies have investigated the biologic
effects of IBS with various particle sizes: 40 μm
to 80 μm, 80 μm to 200 μm, and 200 μm to 500
μm. These studies confirmed that small calci-
um phosphate particles (40 μm to 80 μm) sup-
port bone ingrowth to a similar extent to larger
CONTINUING EDUCATION 2
ones. The BCP degradation and bone substitu-
tion process occurred earlier and faster for IBS
40 μm to 80 μm than for IBS 200 μm to 500
μm. Qualitatively, IBS with small BCP particle
granulometry was shown to be more favorable
for restoration of the initial trabecular structure
IBS (40 μm to 80 μm).
These preliminary results obtained with BCP/
hydrosoluble polymer composites, described as
IBS, demonstrated that they could be used in
endodontics as a possible root canal filling mate-
rial. However, further in vivo investigations and
clinical studies are needed to assess the perfor-
mances of this new injectable bioactive material
in everyday endodontic procedures.
Conclusion
The range of biomaterials in dental surgery, es-
pecially in endodontics, has increased in recent
years. MTA and calcium phosphate biomateri-
als have been assessed as biocompatible and
bioactive alternatives to current filling materi-
als. They have demonstrated their efficiency in
inducing some mineralized tissues. To improve
their ease of use, an important evolution in this
field was observed with the development of
various injectable calcium phosphate bioma-
terials. Composite biomaterials such as inject-
able bone substitutes (consisting of calcium
phosphate in a polymer matrix) could have the
necessary qualities for root canal fillers. They
combine biocompatibility, bioactivity, and the
rheological properties to be injected in a nar-
row root canal.
ABOUT THE AUTHOR
Satyajit Mohapatra, MDS
Post Graduate, Department of Endodontics, Institute of
Dental Sciences, Bhubaneswar, India
Swadheena Patro, MDS
Reader, Department of Endodontics, Institute of Dental
Sciences, Bhubaneswar, India
Sumita Mishra, MDS
Senior Lecturer, Department of Orthodontics, Institute of
Dental Sciences, Bhubaneswar, India
www.compendiumlive.com
ENDODONTIC MATERIALS
Queries to the authors regarding this course may be submit-
ted to authorqueries@aegiscomm.com.
REFERENCES
1. Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari
MA. The radiographic outcomes of direct pulp-
capping procedures performed by dental stu-
dents: a retrospective study. J Am Dent Assoc.
2006;137(12):1699-1705.
2. Costa CA, Hebling J, Hanks CT. Current status
of pulp capping with dentin adhesive systems: a
review. Dent Mater. 2000;16(3):188-197.
3. Pereira JC, Segala AD, Costa CAS. Human pulpal
response to direct pulp capping with an adhesive
system. Am J Dent. 2000;13(3):139-147.
4. Accorinte MLR, Loguercio AD, Reis A, Costa CAS.
Response of human pulps capped with different
self-etch adhesive systems. Clin Oral Investig.
2008;12(2):119-127.
5. Hauman CHJ, Love RM. Biocompatibility of dental
materials used in contemporary endodontic thera-
py: a review. Part 2. Root-canal-filling materials. Int
Endod J. 2003;36(3):147-160.
6. Johnson BR. Considerations in the selection of
a root-end filling material. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 1999;87(4):398-404.
7. Briseno BM, Willershausen B. Root canal sealer cy-
totoxicity on human gingival fibroblasts. 1. Zinc oxide-
eugenol-based sealers. J Endod. 1990;16(8):383-386.
8. Wolfson EM, Seltzer S. Reaction of rat connective
tissue to some gutta-percha formulations. J Endod.
1975;1(12):395-402.
9. Ektefaie MR, David HT, Poh CF. Surgical resolu-
tion of chronic tissue irritation caused by extruded
endodontic filling material. J Can Dent Assoc (Tor).
2005;71(7):487-490.
10. Huang TH, Lii CK, Chou MY, Kao CT. Lactate
dehydrogenase leakage of hepatocytes with
AH26 and AH Plus sealer treatments. J Endod.
2000;26(9):509-511.
11. Ho Y-C, Huang F-M, Chang Y-C. Cytotoxicity of
formaldehyde on human osteoblastic cells is related
to intracellular glutathione levels. J Biomed Mater
Res B Appl Biomater. 2007;83(2):340-344.
11A. Bouillaguet S, Wataha JC, Tay FR, et al. Initial in
vitro biological response to contemporary endodon-
tic sealers. J Endod. 2006;32(10):989-992.
12. Bernáth M, Szabó J. Tissue reaction initiated by
different sealers. Int Endod J. 2003;36(4):256-261.
13. Economides N, Kotsaki-Kovatsi VP, Poulopoulos
A, et al. Experimental study of the biocompatibility
of four root canal sealers and their influence on the
zinc and calcium content of several tissues. J Endod.
1995;21(3):122-127.
14. Lin LM, Rosenberg PA, Lin J. Do procedural er-
rors cause endodontic treatment failure? J Am Dent
Assoc. 2005;136(2):187-193.
December 2017 COMPENDIUM EBOOK SERIES 19
 CONTINUING EDUCATION 2
15. Bystrom A, Claesson R, Sundqvist G. The anti-
bacterial effect of camphorated paramonochloro-
phenol, camphorated phenol and calcium hydroxide
in the treatment of infected root canals. Endod Dent
Traumatol. 1985;1(5):170-175.
16. Gordon TM, Ranly DM, Boyan BD. The effects
of calcium hydroxide on bovine pulp tissue: varia-
tions in pH and calcium concentration. J Endod.
1985;11(4):156-160.
17. Freeman K, Ludington JR, Svec TA, et al. Con-
tinuously infused calcium hydroxide: its influence on
hard tissue repair. J Endod. 1994;20(6):272-275.
18. Fitzgerald M, Chiego DJ, Heys DR. Autoradio-
graphic analysis of odontoblast replacement follow-
ing pulp exposure in primate teeth. Arch Oral Biol.
1990;35(9):707-715.
19. Torneck CD, Moe H, Howley TP. The effect of cal-
cium hydroxide on porcine pulp fibroblasts in vitro.
J Endod. 1983;9(4):131-136.
20. Alliot-Licht B, Jean A, Gregoire M. Compara-
tive effect of calcium hydroxide and hydroxyapatite
on the cellular activity of human pulp fibroblasts in
vitro. Arch Oral Biol. 1994;39(6):481-489.
21. Cox CF, Subay RK, Ostro E, Suzuki SH. Tunnel
defects in dentin bridges: their formation following
direct pulp capping. Oper Dent. 1996;21(1):4-11.
22. Calişkan MK, Sen BH. Endodontic treatment of
teeth with apical periodontitis using calcium hy-
droxide: a long-term study. Endod Dent Traumatol.
1996;12(5):215-221.
23. Mackie IC, Hill FJ, Worthington H V. Comparison
of two calcium hydroxide pastes used for endodon-
tic treatment of non-vital immature incisor teeth.
Endod Dent Traumatol. 1994;10(2):88-90.
24. Torabinejad M, Hong CU, McDonald F, Pitt Ford
TR. Physical and chemical properties of a new root-
end filling material. J Endod. 1995;21(7):349-353.
25. Dammaschke T, Gerth HU, Züchner H, Schäfer
E. Chemical and physical surface and bulk mate-
rial characterization of white ProRoot MTA and two
Portland cements. Dent Mater. 2005;21(8):731-738.
26. Camilleri J, Montesin FE, Brady K, et al. The con-
stitution of mineral trioxide aggregate. Dent Mater.
2005;21(4):297-303.
27. Keiser K, Johnson CC, Tipton DA. Cytotoxicity of
mineral trioxide aggregate using human periodontal
ligament fibroblasts. J Endod. 2000;26(5):288-291.
28. Fridland M, Rosado R. Mineral trioxide aggregate
(MTA) solubility and porosity with different water-
to-powder ratios. J Endod. 2003;29(12):814-817.
29. Eldeniz AU, Hadimli HH, Ataoglu H, Orstavik D.
Antibacterial effect of selected root-end filling ma-
terials. J Endod. 2006;32(4):345-349.
30. Bates CF, Carnes DL, del Rio CE. Longitudinal
sealing ability of mineral trioxide aggregate as a
root-end filling material. J Endod. 1996;22(11):575-
578.
20 COMPENDIUM EBOOK SERIES December 2017
ENDODONTIC MATERIALS
31. Matt GD, Thorpe JR, Strother JM, McClana-
han SB. Comparative study of white and gray
mineral trioxide aggregate (MTA) simulating a
one- or two-step apical barrier technique. J Endod.
2004;30(12):876-879.
32. Sarkar NK, Caicedo R, Ritwik P, et al. Physico-
chemical basis of the biologic properties of mineral
trioxide aggregate. J Endod. 2005;31(2):97-100.
33. Balto HA. Attachment and morphological be-
havior of human periodontal ligament fibroblasts
to mineral trioxide aggregate: a scanning electron
microscope study. J Endod. 2004;30(1):25-29.
34. Koh ET, McDonald F, Pitt Ford TR, Torabinejad
M. Cellular response to mineral trioxide aggregate.
J Endod. 1998;24(8):543-547.
35. Thomson TS, Berry JE, Somerman MJ, Kirkwood
KL. Cementoblasts maintain expression of osteocal-
cin in the presence of mineral trioxide aggregate.
J Endod. 2003;29(6):407-412.
36. Laurent P, Camps J, DeMéo M, et al. Induc-
tion of specific cell responses to a Ca3SiO5-
based posterior restorative material. Dent Mater.
2008;24(11):1486-1494.
37. Laurent P, Camps J, About I. Biodentine™
induces TGF-β1 release from human pulp cells
and early dental pulp mineralization. Int Endod J.
2012;45(5):439-448.
38. Lesot H, Osman M, Ruch JV. Immunofluorescent
localization of collagens, fibronectin, and laminin
during terminal differentiation of odontoblasts. Dev
Biol. 1981;82(2):371-381.
39. Raskin A, Eschrich G, Dejou J, About I. In vitro
microleakage of Biodentine as a dentin substitute
compared to Fuji II LC in cervical lining restorations.
J Adhes Dent. 2012;14(6):535-542.
40. Nowicka A, Lipski M, Parafiniuk M, et al. Re-
sponse of human dental pulp capped with bio-
dentine and mineral trioxide aggregate. J Endod.
2013;39(6):743-747.
41. Soundappan S, Sundaramurthy JL, Raghu S, Na-
tanasabapathy V. Biodentine versus mineral trioxide
aggregate versus intermediate restorative material
for retrograde root end filling: an invitro study.
J Dent (Tehran). 2014;11(2):143-149.
42. Daculsi G, Bouler JM, LeGeros RZ. Adaptive
crystal formation in normal and pathological calcifi-
cations in synthetic calcium phosphate and related
biomaterials. Int Rev Cytol. 1997;172:129-191.
43. Boone ME, Kafrawy AH. Pulp reaction to a trical-
cium phosphate ceramic capping agent. Oral Surg
Oral Med Oral Pathol. 1979;47(4)369-371.
44. Chohayeb AA, Adrian JC, Salamat K. Pulpal re-
sponse to tricalcium phosphate as a capping agent.
Oral Surg Oral Med Oral Pathol. 1991;71(3):343-345.
45. Frank RM, Klewansky P, Hemmerle J, Tenen-
baum H. Ultrastructural demonstration of the
importance of crystal size of bioceramic powders
CONTINUING EDUCATION 2
implanted into human periodontal lesions. J Clin
Periodontol. 1991;18(9)669-680.
46. LeGeros RZ. Calcium phosphates in oral biology
and medicine. Monogr Oral Sci. 1991;15:1-201.
47. Al-Sanabani JS, Madfa AA, Al-Sanabani FA. Ap-
plication of calcium phosphate materials in den-
tistry. Int J Biomater. 2013;2013:876132.
48. Jaber L, Mascres C, Donohue WB. Electron
microscope characteristics of dentin repair after
hydroxylapatite direct pulp capping in rats. J Oral
Pathol Med. 1991;20(10):502-508.
49. Kouassi M, Michaïlesco P, Lacoste-Armynot A,
Boudeville P. Antibacterial effect of a hydraulic cal-
cium phosphate cement for dental applications.
J Endod. 2003;29(2):100-103.
50. Krell KV, Madison S. Comparison of apical leak-
age in teeth obturated with a calcium phosphate
cement or Grossman’s cement using lateral conden-
sation. J Endod. 1985;11(8):336-339.
51. El Briak H, Durand D, Boudeville P. Study of a
hydraulic DCPA/CaO-based cement for dental ap-
plications. J Mater Sci Mater Med. 2008;19(2):737-
744.
52. Roy CO, Jeansonne BG, Gerrets TF. Effect of
an acid environment on leakage of root-end filling
materials. J Endod. 2001;27(1):7-8.
53. Mattioli Belmonte M, De Benedittis A, Mongiorgi
R, et al. Bioactivity of chitosan in dentistry. Pre-
liminary data on chitosan-based cements. Minerva
Stomatol. 1999;48(12):567-576.
54. Sugawara A, Chow LC, Takagi S, Chohayeb H.
In vitro evaluation of the sealing ability of a cal-
cium phosphate cement when used as a root canal
sealer-filler. J Endod. 1990;16(4):162-165.
55. White JM, Goodis H. In vitro evaluation of an
www.compendiumlive.com
ENDODONTIC MATERIALS
hydroxyapatite root canal system filling material.
J Endod. 1991;17(11):561-566.
56. Takagi S, Chow LC, Hirayama S, Suga-
wara A. Premixed calcium-phosphate cement
pastes. J Biomed Mater Res B Appl Biomater.
2003;67(2):689-696.
57. Yoshikawa M, Hayami S, Tsuji I, Toda T. His-
topathological study of a newly developed root
canal sealer containing tetracalcium-dicalcium
phosphates and 1.0% chondroitin sulfate. J Endod.
1997;23(3):162-166.
58. Nevins A, Finkelstein F, Laporta R, Borden BG.
Induction of hard tissue into pulpless open-apex
teeth using collagen-calcium phosphate gel. J En-
dod. 1978;4(3):76-81.
59. Nevins AJ, LaPorta RF, Borden BG, Spangberg
LS. Pulpotomy and partial pulpectomy procedures
in monkey teeth using cross-linked collagen-calcium
phosphate gel. Oral Surg Oral Med Oral Pathol.
1980;49(4):360-365.
60. Grimandi G, Weiss P, Millot F, Daculsi G. In vitro
evaluation of a new injectable calcium phosphate
material. J Biomed Mater Res. 1998;39(4):660-666.
61. Nery EB, LeGeros RZ, Lynch KL, Lee K. Tissue
response to biphasic calcium phosphate ceramic
with different ratios of HA/beta TCP in periodontal
osseous defects. J Periodontol. 1992;63(9):729-735.
62. Van Blitterswijk CA, Grote JJ, Kuijpers W, et al.
Macropore tissue ingrowth: a quantitative and quali-
tative study on hydroxyapatite ceramic. Biomateri-
als. 1986;7(2):137-143.
63. Higashi T, Okamoto H. Influence of particle
size of hydroxyapatite as a capping agent on
cell proliferation of cultured fibroblasts. J Endod.
1996;22(5):236-239.
December 2017 COMPENDIUM EBOOK SERIES 21
CONTINUING EDUCATION 2 QUIZ
Bioactive Materials in Endodontics: An Evolving
Component of Clinical Dentistry
Satyajit Mohapatra, MDS; Swadheena Patro, MDS; and Sumita Mishra, MDS
THIS COURSE IS AVAILABLE ONLINE AT: COMPENDIUMLIVE.COM/GO/UPDATESENDO2.
ENTER PROMO CODE: UPEND2
1. 
The success of pulp capping therapy
depends on:
A. complete disinfection through
chemomechanical debridement of the
pathological or necrotic pulp tissue.
B. hermetically sealing the root canal system from
the oral environment.
C. hermetically sealing the root canal system from
the periapical environment.
D. All of the above
2. Major difficulties are created for complete
disinfection, shaping, and filling of a root canal
to prevent bacterial infiltration and ingress
due to:
A. the inability to use antibiotics within the canal.
B. the inability to use antiseptic agents in the
canal.
C. the complexity of the pulp root canal and its
ramifications.
D. the inability to adequately visualize the access
opening.
3. Biocompatibility tests have shown that all the
currently used filling materials, including gutta
percha (GP):
A. cause local adverse effects on vital tissues.
B. are 100% inert.
C. only are problematic in cases where there is a
preexisting periapical abscess.
D. have been shown to be non-cytotoxic.
4. Numerous commonly used root canals sealers,
such as epoxy resin-based, calcium hydroxide-
based, and zinc oxide-eugenol-based sealers
possess a marked cytotoxic and tissue-irritating
potency, notably for:
A. periodontal ligament cells.
B. osteoblasts.
C. cementoblasts.
D. cementoclasts.
5. Calcium hydroxide, or Ca(OH)2, has a pH of
approximately:
A. 3 B. 5 C. 9 D. 12
Course is valid from 12/1/2017 to 12/31/2020. Participants
must attain a score of 70% on each quiz to receive credit. Par-
ticipants receiving a failing grade on any exam will be notified
and permitted to take one re-examination. Participants will
receive an annual report documenting their accumulated
credits, and are urged to contact their own state registry
boards for special CE requirements.
2 Hours CE Credit
6. When calcium hydroxide is used as a pulp
capping agent, it induces:
A. hematomas.
B. dentin bridge formation.
C. apexogenisis.
D. substance P recruitment.
7. 
The mechanism of formation of hard tissues is by
the calcium oxides of MTA that react with tissue
fluids to form:
A. calcium hydroxide.
B. potassium hydroxide.
C. calcium fluoride.
D. potassium fluoride.
8. Interleukin [IL]-1α, IL-1β, osteocalcin, and alkaline
phosphatase are:
A. cytotoxic to periapical bacteria.
B. osteoblastic activity markers.
C. indicators of periapical pain.
D. rarely seen all together in the same histologic
sample.
9. The calcium phosphate biomaterial can favor
osteoconduction by:
A. its low tensile strength.
B. high tensile strength.
C. its porosity.
D. high torsion aspect ratio in relation to
osteoblastic cells.
10. T
 he size and lack of accessibility of the various
endodontic sites have necessitated the
development of:
A. gaseous forms of calcium phosphate cement.
B. injectable forms of calcium phosphate cement.
C. biodegradable forms of calcium phosphate
cement.
D. solid forms of calcium phosphate cement.
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Concerns or complaints about a CE provider may be directed
to the provider or to ADA CERP at www.ada.org/cerp. Provider #: 209722.
 PULP VITALITY
TESTER

FEATURES:
• Automatic one-button operation.
• Three rates of stimulus increase – slow, medium and fast.
• Unit remembers the previous rate of speed programmed.
• Micro-processor performs a self-test assuring proper function of the unit every time.
• Includes 4 autoclavable probe tips - Short, Long, Precision Labial & Precision Lingual.

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