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Biocompatibility of endodontic materials

Article · January 2016

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 BIOCOMPATIBILITY OF ENDODONTIC MATERIALS

Dr. Shrivastava A*,Dr. Syed G.A**, Dr.Palekar A***, Dr.Mantri V****

Abstract:
Materials used in dentistry come into direct contact with the oral mucosa, the pulp, the
periapical tissues & the hard tissues of the teeth. Due to this intimate, long term contact,
the materials should exhibit a high degree of biocompatibility. Given the importance of
biocompatibility to dental materials, it is surprising how few practitioners understand what
biocompatibility really is. In this article, the biocompatibility of endodontic materials has
been discussed.
Key Words: Biocompatibility, Irrigating agent, Intracanal medicaments, Sealer,
Guttapercha

INTRODUCTION

The complexity & technical nature of

biocompatibility issues may appear
beyond the scope of practicing dentists.
However, these issues have profound
ethical, social, technical and legal effects
on dental practice.1 Biocompatibility is
defined as ability of the material to elicit
an appropriate biologic response in a given
application in the body.2
Ideally, a dental material used in the oral
cavity should not interact negatively with
oral or dental tissue. In this respect, it
should be: 3
 Harmless to the pulp & the soft tissues.
 It should contain no toxic diffusible
substance that can be absorbed into the
circulatory system to cause a systemic
toxic response.
 Should be free of potentially
sensitizing agents that could lead to an
allergic response.
 Should have no carcinogenic potential.
*Post Graduate Student Department Of
Conservative Dentistry & Endodontics
MDCRC, Indore ( M.P.)
**Reader & Guide , ,MDCRC Indore (M.P.)
***Professor & HOD, MDCRC Indore(M.P.)
****Professor ,MDCRC Indore (M.P.)
HISTORICAL BACKGROUND
Although the concept of ethical treatment
of patients extends back to the time of
Hippocrates (460-377 B.C), the idea that
new dental materials must be tested for
safety & efficacy before clinical use is
much more recent. As late as the mid
1800s, dentists tried new materials for the
first time by putting them into patient’s
mouths. Many exotic formulations were
used. For example, Fox developed a
“fusible metal” that consisted of bismuth,
lead, and tin, which he melted & poured
into the cavity preparation at a temperature
of approximately 1000C. Even G.V. Black
used patients to test many of his new ideas
for restorative materials, such as early
amalgams. In the past decade, new
molecular biological & imaging techniques
have been applied to assist our
understanding of the biological response to
materials. Today, the field of
biocompatibility testing has reached a
point where some prediction of biological
properties & the future will likely provide
the ability to design materials that elicit
customized biological responses.2
BIOCOMPATIBILITY
REQUIREMENTS

NJDSR Volume I number 4 January 2016 44

Certain substances released from some
dental materials, may produce biological
responses at the localized sites like the
pulp, periodontium, root apex, or nearby
soft tissues such as buccal mucosa, tongue
etc.
These can enter the body systems through
several routes, hence, biocompatibility
requirements are:
1. They should not be harmful to the pulp
or soft & hard tissues of the oral cavity
in particular & the whole body in
general.
2. They should not sensitize & produce
allergic reactions.
3. They should not undergo
biodegradations.
4. They should not contain any toxic
diffusible substances which get
released & enter into the circulatory
system.
5. They should not create immune-
toxicity i.e they should not alter the
cell structures of the immune systems,
by changing the cellular functions.
6. They should not be carcinogenic.
7. They should not show estrogenicity &
should not contain xeno estrogens.
BIOCOMPATIBILITY OF
ENDODONTIC MATERIALS
1. IRRIGANTS & INTRACANAL
MEDICAMENTS:
SODIUM HYPOCHLORITE:
Pashley et al. (1985) demonstrated the
cytotoxicity of NaOCl using three
independent biological models. They
found that a concentration as low as
1:1000 (v/v) NaOCl in saline caused
complete haemolysis of red blood cells in
vitro. Heggers et al. (1991) examined
wound healing relative to irrigation and
bactericidal properties of NaOCl in in vitro
and in vivo models. They concluded that
0.025% NaOCl was the safest
concentration to use because it was
bactericidal but not tissue-toxic. Different
concentrations of NaOCl (e.g. 0.5, 1, 2.5
NJDSR Volume I number 4 January 2016
or 5.25%) are currently used as root-canal
irrigants. Clinical tests showed that sodium
hypochlorite at 0.5 or 5% concentration
has similar clinical efficiency in
supporting mechanical debridement of the
root canal.Most complications of the use
of sodium hypochlorite appear to be the
result of its accidental injection beyond the
root apex which can cause violent tissue
reactions characterized by pain, swelling,
haemorrhage, and in some cases the
development of secondary infection and
paraesthesia. Hypersensitivity reactions to
sodium hypochlorite have also been
reported. 4
ETHYLENE DIAMINE
TETRAACETIC ACID:
Both neutral and alkaline EDTA showed
moderate-to-severe cytotoxicity in a
concentration dependent manner. In
addition, EDTA has been shown to inhibit
the substrate adherence capacity of
macrophages as well as the binding of
vasoactive peptide to macrophage
membranes in vitro. These results suggest
that leakage of EDTA to periapical tissues
during root-canal preparation may inhibit
macrophage function, and thus alter the
inflammatory response in periapical
lesions. EDTA has been shown to have
weak antibacterial and antifungal
4
properties.
CHLORHEXIDINE:
It may be a useful substitute in those
patients who are allergic to sodium
hypochlorite. It is important to note that
various symptoms of immediate
hypersensitivity, including anaphylactic
reactions, have been reported after topical
treatment with chlorhexidine. Results from
an in vitro study on the toxicity of
chlorhexidine to human gingival cells
showed that the toxic potency of
chlorhexidine is dependent on the length of
exposure and the composition of the
exposure medium. 4
CALCIUM HYDROXIDE:
45
 Calcium hydroxide has been reported to
have a detrimental effect on periodontal
tissues when used as an intra canal
medicament during routine endodontic
therapy. Blomlof et al. (1988) observed
that calcium hydroxide could negatively
influence marginal soft tissue healing and
suggested the completion of endodontic
therapy prior to the removal of cementum
as might occur during periodontal therapy.
Breault et al. (1995) reported that the use
of calcium hydroxide demonstrated an
increased but not statistical significant
inhibition of attached human gingival
fibroblasts and proposed that calcium
hydroxide should be avoided as an interim
medicament when trying to regenerate or
establish new attachment in tissues
adjacent to endodontically involved teeth.4
2. ABSORBENT PAPER POINTS
There are many brands on the market, and
the points are made either to given ISO
sizes or in various non-standardized
dimensions. The points are often delivered
sterile or sterilized, but no information is
available on the method of sterilization.
Although absorbent paper points are not
intended to remain in contact with vital
tissue, cellulose particles may be found in
the periapical region of teeth associated
with inflammatory lesions. Thus, there are
reasons to evaluate the biological effects of
absorbent paper points used in dentistry.
Prior to any extensive usage test, it is
recommended that selected initial tests be
performed on the to be evaluated for
biological responses.5
3. SEALERS
Several methods have been used to
evaluate the biocompatibility of
endodontic sealers. One of the most
practical and widely used methods is the
implantation of the material into the
subcutaneous connective tissue of rats. The
irritating effect of the materials can be
evaluated by the histopathological
examination of tissue response around the
implants.6Like most sealers AH26 is very
NJDSR Volume I number 4 January 2016
toxic when freshly prepared. The toxicity
of AH26 sealer is attributed to the release
of a very small amount of formaldehyde as
a result of the chemical setting process.
Calcium hydroxide and Sealapex impaired
the status of the periapical tissue when the
materials were extruded through the apex.7
4. OBTURATING MATERIALS
Gutta-percha is considered to have
acceptable biocompatibility with a low
degree of toxicity.7 It was found that
cytotoxic effects varied among brands.8
Silver points can undergo corrosion.
Corrosion of the point with release of toxic
products from the metal was believed to
initiate or support inflammatory reactions,
and the retrieval of silver points lost in the
canal of teeth with post-treatment disease
cast doubts on the sealing ability of these
fillings.9
CONCLUSION:
Biocompatibility is very relevant to
dentistry because they rely heavily on
materials that remain in intimate contact
with living tissues for long periods.
Decision about the biologic safety of
materials are as much philosophical as
scientific. Because no material can be
proven 100% safe, the decision to use a
material in the mouth must balance the
potential risks and benefits.1
REFRERENCES:
1) Wataha JC: Principles of
biocompatibility for dental
practitioners. J Prosthet Dent
2001;86:203-209.
2) J Kenneth, Anusavice: Phillip’s
science of dental materials, 11th ed.
St.Louis, Missouri: Elsevier,2003:171.
3) Schedle A, Ortengren U, Eidler N,
Gabauer M, Hensten A. Do adverse
effect of dental materials exist? What
are the consequences, and how can
they be diagnosed and treated. Clin
Oral Impl Res 2007;18(3):232-256.
4) Hauman C.H.J, Love R.M,
Biocompatibility of dental materials
46
 used in contemporary endodontic
therapy: A Review. Part1. Intracanal
drugs and substances. International
Endodontic Journal 2003;36:75-85.
5) Moller B, Pettersen AH. Biological
evaluation of absorbent paper points.
International Endodontic Journal
1985;18:183-186.
6) Silveira CMM, Pinto SCS, Zedebski
RAM, Santos FA, Pilatti GL.
Biocompatibility of four root canal
sealers: A histopathological evaluation
in Rat subcutaneous connective tissue.
Braz Dent J 2011;22(1):21-27.
7) Hauman C.H.J, Love R.M,
Biocompatibility of dental materials
used in contemporary endodontic
therapy: A Review. Part2. Root-canal-
filling materials. International
Endodontic Journal 2003;36:147-160.
8) Dahl JE. Toxicity of endodontic filling
materials. Endodontic Topics
2005;12:39-43.
9) Orstavik D. Materials used for root
canal obturation: technical, biological
and clinical testing. Endodontic Topics
2005;12:25-38.

NJDSR Volume I number 4 January 2016 47

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