ENDODONTOLOGY Volume: 26 Issue 2 December 2014 ORIGINAL RESEARCH

Evaluation of pH and calcium ion diffusion from MTA

Fillapex and Sealapex through simulated external
root resorption -An In Vitro Study
Swati Srivastava1, Amrita Majumdar2, Rohit Kochhar3,
Ruchika Dewan4, Anil Dhingra5
__________________________________________________________________________________________________

1,2Seniorlecturer, 3Professor and Head, 4Professor, Department of Conservative dentistry and Endodontics, ITS Dental College,
Hospital & Research Centre, Greater Noida
5Professor and Head, Department of Conservative dentistry and Endodontics, DJ Dental college, Modinagar, UP

E-mail ID: swatisrivastava412@gmail.com

Abstract:
Objectives: To evaluate in-vitro, the pH and calcium ion diffusion from MTA Fillapex and Sealapex through simulated external
root resorption.
Materials and Method: Thirty single rooted mandibular premolars were divided into three groups of ten teeth each. Access
openings were done and canals were instrumented by crown down technique. To simulate external root resorption, standardized
defects were created. RDT was evaluated using Digital Radiovisiography. The root canal and external defects were irrigated
followed by thorough drying with paper points. In group I, MTA Fillapex (Angelus) and in group II, Sealapex (Sybron Endo)
was used as root canal sealer. In group III, pulp space was not filled with any material. All root canals were obturated with F2
cones (Dentsply). The teeth were sealed with three coats of nail varnish except at the defect. Each tooth was immersed in a vial
containing 10 ml of HPLC water and stored in incubator at 37°C. The Ca2+ concentrations and pH values of the immersion media
were measured at 1, 3, 7, 14, and 28 days using atomic absorption spectrophotometer and by pH meter respectively. The results
were submitted to ANOVA and Tukey’s test.
Results: The mean pH and Calcium values of Sealapex (group II) exhibited very high significant values (p < 0.001) at all
evaluation periods.
Conclusion: Sealapex provided highest pH and calcium release as compared to other groups (p < 0.001).

Keywords: MTA Fillapex, Sealapex, pH, Calcium ion diffusion, External root resorption.

Introduction: capable of producing a suitable environment for

Tooth resorption is a perplexing problem
where the etiologic factors are vague and not clearly
defined. Early diagnosis and prompt treatment are the
key factors which determine the success of the
treatment.1 One of the causes of perforating internal
inflammatory root resorption, external inflammatory
root resorption and cervical root resorption is
presence of infected or necrotic pulp. The treatment
can be done successfully by removal or reduction of
source of infection via root canal therapy.
Application of intracanal materials rich in Ca ions
stops bone resorption by inhibiting osteoclastic
activity and promoting cell migration, differentiation
and mineralization. The release of hydroxyl ions
causes increase in pH of surrounding dentinal fluid
disrupting the energy supply and thus causing cell
lysis.
Since its introduction calcium hydroxide has
been widely used in endodontics. It is a strong
alkaline substance, which has pH of approximately
11-13. It also has antimicrobial activity, tissue
dissolving ability, inhibits resorption and induces
repair by hard tissue formation.2 A large number of
studies have shown that MTA is biocompatible, non
toxic, insoluble in presence of tissue fluids and is
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regeneration of periradicular tissues. The remaining
dentin serves as a slow release system of intracanal
MTA-derived Ca to the potential healing site. MTA’s
physical handling is difficult due to its wet sand
consistency. Recently MTA based sealers have been
developed which facilitates easy handling. They are
biocompatible and stimulate mineralization.3 They
also exhibit a higher adhesiveness to dentin than
conventional zinc oxide/eugenol-based cements.
MTA Fillapex (Angelus, Brazil) is a MTA
based root canal sealer that promotes the deposition
of hard tissue at the root apex and perforation sites.
According to the manufacturer, its composition after
mixture is basically MTA, salicylate resin, natural
resin, bismuth and silica.4 It has got low solubility in
contact with tissue fluids and excellent viscosity for
insertion. Sealapex (Sybron Endo, USA) is another
commercial product, specifically developed to be
used as a sealer. It is a viscous mix of calcium
hydroxide and iodoform. It contains calcium
hydroxide that will only be biologically active if
calcium and hydroxyl ions are released over time.5
Ideally, a material should present alkaline pH and
calcium release to stimulate tissue mineralization.
 Evaluation of pH and calcium ion diffusion from MTA Fillapex and Sealapex
through simulated external root resorption -an in vitro study
Therefore, the aim of this study was to
evaluate the pH and the Ca ion release from MTA
Fillapex and Sealapex respectively, through
simulated external root resorption on 1, 3, 7, 14 & 28
days respectively.
Materials and Method:
Sample Preparation: Thirty single rooted human
mandibular premolars were procured, not less than
one month from the start of the experiment. The
selected specimens were stored and surfaced
adhering to infection control protocols as prescribed
by Centre for Disease Control Global (CDC). All the
teeth were decoronated at the cementoenamel
junction using a slow speed diamond disk and apical
12 mm specimens were obtained. Instrumentation
was held by a single operator. A no 10 K file
(Dentsply, Maillefer, Switzerland) was introduced
into the root canal until it was visible at the apical
foramen. The working length was determined by
subtracting 1mm from this length. Root canal
instrumentation was performed using the ProTaper
Universal rotary instrument upto F2 (Dentsply,
Maillefer) at a controlled speed of 300 rpm (X smart
Dentsply). During cleaning and shaping, irrigation
was done using a total of 5ml, 2.5% NaOCl at each
file size. To simulate external root resorption, defects
were created using ISO No. 12 cylindrical diamond
bur at high speed and water spray, exposing dentin in
approximately middle-3rd of root surface. The
remaining dentin thickness was standardized to 1mm.
To determine the remaining dentin thickness after
canal instrumentation and cavity preparation, digital
radiovisiography was obtained using paralleling
technique. For each specimen, 3 measurements were
made at coronal, middle and apical levels between
the base of the cavity and the canal outline. The depth
was modified so as to standardize the RDT =
1+0.1mm.
Following radiographic assessments, the
root canal and external defects were irrigated with
17% EDTA and 2.5% NaOCl to remove the smear
layer and then rinsed with 10ml saline. The root
canals were dried with sterile absorbent paper points.
All root canals were filled by the single cone
technique with the use of master gutta-percha F2
cone (Dentsply, Maillefer). The teeth were divided
into experimental groups of 10 specimens each
according to the sealer as follows:
Group I: MTA Fillapex (Angelus, Brazil)
Group II: Sealapex (Sybron Endo, USA)
Group III: not filled with any material (Control)
The materials were handled according to the
manufacturer’s instructions and inserted into the root
canals with a lentulospiral (Dentsply, Maillefer). The
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calibrated master gutta-percha point was coated by
sealer and inserted into the root canal until it reached
the working length. The teeth were sealed with three
coats of nail varnish except at the defect. Each tooth
was immersed in a vial containing 10 ml of HPLC
water and stored in an incubator at 37°C to simulate
the oral environment.
pH analysis: The water pH in which the samples
were immersed was measured at 1, 3, 7, 14 and 28
days. This was performed through a digital pH meter
calibrated with standard solutions of pH 4.0 and 7.0.
The obtained pH values were submitted to ANOVA
and Tukey’s test, with level of significance at 5%.
Calcium ion releasing analysis: Calcium ions
released were measured through an atomic absorption
spectrophotometer (AA6800, Shimadzu, Tokyo,
Japan), equipped with a specific cathode lamp for
reading. The reading of calcium ions released were
executed at the same periods of the pH reading. Data
was submitted to ANOVA and Tukey’s test, both
with level of significance at 5%.
Results:
pH analysis: The mean pH values of the
experimental and the control groups on allocated
days showed statistically very highly significant
values. The mean pH values of Sealapex (group II)
exhibited highest values at all evaluation periods and
increased from day 1 to day 28. [Table I]
Multiple group comparison was done using
Tukey HSD test. On allocated days, the intergroup
comparison of pH values proved to be statistically
very highly significant (p < 0.001).
ANOVA test was used to evaluate mean pH
values of respective groups at various evaluation
periods. Group 1 & group 2 demonstrated rise of
their mean pH values from day 1 to day 28. The
results being statistically very highly significant for
both the groups. Group 2 exhibited greater mean pH
values amongst the tested groups. Data with the
control group did not prove to be significant for the
mean pH values.
Bonferroni multiple comparison test was
used for interday comparison of pH values within
respective experimental and control groups.
Analysis of Calcium ion release: The mean calcium
values of the experimental and the control groups on
allocated days showed statistically very highly
significant values. The mean Calcium values of
Sealapex (group II) exhibited highest values at all
evaluation periods and increased from day 1 to day
28. [Table II]
Multiple group comparison was done using
Tukey HSD test. On allocated days, the intergroup
comparison of Calcium values proved to be
statistically very highly significant (p < 0.001).
ANOVA test was used to evaluate mean
Calcium values of respective groups at various
 Evaluation of pH and calcium ion diffusion from MTA Fillapex and Sealapex
through simulated external root resorption -an in vitro study

evaluation periods. All the tested groups activity and formation of resorbing cells. Frank and
demonstrated rise in the mean Calcium values from Weine proposed that the treatment of internal and
Day 1 to day 28 with group 2 demonstrating the external resorption has been limited to the use of
maximum rise in the values amongst all the groups. calcium hydroxide or other bio-materials to lessen the
Bonferroni multiple comparison test was inflammatory response and to help promote the
used for interday comparison of Calcium values deposition of a hard tissue barrier, while providing a
within respective experimental and control groups for biologic seal.
which statistically very high significant difference Several studies have demonstrated that
was observed. resorption may be prevented or controlled by using
Calcium hydroxide as root canal filling material by
Table I: (pH)-Intergroup comparison of mean pH stimulation of the periapical tissues in order to
in different groups at various time intervals. maintain health or promote healing. Calcium
Time Group I Group II Group Statistical hydroxide has a very high pH (hydroxyl group) that
interval (MTA (Sealapex) III significance encourages repair and active calcification. There is an
Fillapex) (Control) “p”
1 day 6.21 + 7.08+.02 6.30+.03 <0.001
initial degenerative response in the immediate
0.01 vhs vicinity followed rapidly by a mineralization and
3 days 6.44+ 7.31+ .04 6.33+ <0.001 ossification response. The alkaline pH of calcium
.04 .03 vhs hydroxide neutralizes lactic acid from osteoclasts and
7 days 6.47+ 7.42+ .03 6.30+ <0.001 prevents dissolution of mineralized components of
.01 .02 vhs teeth. This pH also activates alkaline phosphatase
14 6.49+ 7.41+ .03 6.32+ <0.001 that plays an important role in hard tissue formation.
days .02 .03 vhs Calcium hydroxide activates the calcium-dependent
28 6.51+ 7.47+ .06 6.30+ <0.001 adenosine triphosphatase reaction associated with
days .04 .03 vhs hard tissue formation.7 Calcium hydroxide diffuses
through dentinal tubules and may communicate with
Table II (Ca)- Intergroup comparison of mean the periodontal ligament space to arrest external root
Calcium ion release in different groups at various resorption and accelerate healing.
time intervals. The rationale for the addition of calcium
Time Group I Group II Group Statistical
interval (MTA (Sealapex) III significance
hydroxide to root canal sealers is from observations
Fillapex) (Control) “p” of bases and liners containing the material and their
1 day 0.42+ 0.70+ .04 0.37+ <0.001 antibacterial and tissue repair abilities. This is exerted
.01 .03 vhs via the leaching of calcium and hydroxyl ions to
3 days 1.90+ 2.30+ .04 2.11+ <0.001 surrounding tissues. Even though calcium hydroxide
.01 .04 vhs has low solubility and diffusibility, unless calcium
7 days 4.20+ 4.81+ .04 4.50+ <0.001 and hydroxyl ions dissociate out of the sealer, it will
.02 .10 vhs not promote the expected healing effects on
14 6.96+ 8.81+ .06 4.88+ <0.001 surrounding tissues.
days .08 .05 vhs
Mineral trioxide aggregate (MTA) has been
28 12.92+ 13.53+ 6.75+ <0.001
days .05 .06 .12 vhs
extensively studied. It was designed to be used in
pathologic or iatrogenic root perforations. Studies
Discussion: have shown that MTA promotes favorable tissue
External root resorption is a pathological reactions characterized by the absence of severe
process which tends to occur following a wide range inflammatory reactions, the presence of a fibrous
of mechanical or chemical stimuli such as infection, capsule, and the induction of mineralized repair
pressure, trauma or orthodontic tooth movement. It tissue. However, despite its favorable characteristics,
may seriously compromise the longevity of a tooth to MTA does not exhibit the physical properties needed
such an extent that it may result in its early loss; to be used as a endodontic sealer, owing to its
therefore it is important that diagnosis and treatment working time, setting time, and difficult handling. 8
occur at an early stage.6 Newer developments of MTA include its use
Glossary of contemporary terminology for as root canal sealer. MTA Fillapex (Angelus, Brazil)
endodontics has defined resorption as a condition a formulation of MTA-based cement was launched to
associated with either physiologic or pathologic be used as root canal sealer. It has excellent viscosity
dissolution of mineralized tissues such as dentin, for insertion and promotes the deposition of hard
cementum and /or both resulting in a loss of these tissue at the root apex and perforation sites. MTA
tissues by osteoclasts and osteoclast like cells. The contain calcium oxide and presents a similar
treatment of root resorption requires the elimination mechanism of action to calcium hydroxide. Calcium
of the inflammatory process and inhibition of the hydroxide or calcium oxide-containing cements have
been suggested as obturating materials because of
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 Evaluation of pH and calcium ion diffusion from MTA Fillapex and Sealapex
through simulated external root resorption -an in vitro study
their ability to dissociate into calcium and hydroxyl
ions, resulting in a higher pH in the adjacent medium
and inducing mineralized tissue formation. Similar
condition occurs to MTA-based sealers.9 Ozdemir et
al (2008) investigated the diffusion of calcium ions
over a period of time with intracanal application of
MTA by simulating external root resorption and
found a significant increase in calcium ion
concentration with time.
However the effect of remaining dentin
thickness over calcium ion release was not
considered. Hence in this study, external root
resorption was simulated by creating defects on the
external root surface and the remaining dentin
thickness was standardized so as to find out the
consistent release of calcium ions and hydroxyl ions
through equal lengths of dentinal tubules in the
middle one third area of the root (apical 12mm). Thus
the depth of cavity was variable in our study,
depending upon the remaining dentin thickness. After
specific periods pH is determined with pH meter and
calcium release is measured with atomic absorption
spectrophotometer.
Sealapex (SybronEndo, Glendora, CA,
USA) is a material specifically developed to be used
as a sealer that contains calcium oxide (CaO), which
in contact with water forms calcium hydroxide.
Sealapex has been shown to induce only a mild
inflammatory reaction when it contacts the periapical
tissues. The present study aimed at reducing the
treatment time to a single appointment time frame
with the use of MTA Fillapex and Sealapex. After
complete chemo-mechanical debridement of the root
canal, obturation can be done on the same visit.
Treatment of external root resorption
requires elimination of the inflammatory process and
inhibition of osteoclastic activity. Non-surgical root
canal therapy has been performed with MTA Fillapex
and Sealapex as root canal sealers. The release of Ca
ions through dentinal tubules is necessary for
activation of adenosine triphosphatase that helps in
cell migration, differentiation and mineralization. The
Ca also reacts with the tissue carbonic gas, forming
calcium carbonate which favours mineralization. In
MTA-based materials, the chemical reaction that
takes place during setting results is the formation of
calcium hydroxide, which subsequently dissociates
into calcium and hydroxyl ions which increase the
pH of the areas.
Sealapex showed greater pH and calcium
release compared to MTA Fillapex at all-time
intervals which is consistent with previously
conducted studies. The reason for this difference may
be related to differences in the percentage of
extractable calcium hydroxide in the content of
sealers or to the intrinsic properties of these materials
which may lead to different chemical reactions
interfering in hydroxyl and calcium ions release and
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in their solubility. High release of calcium from
sealapex can be explained by the intrinsic properties
of the sealer. Sealapex has a poorly formed matrix
and low dimensional liability. It also exhibits very
high water absorption. Thus it becomes a porous
material and permits a marked ingress of water. This
water will facilitate continuous reaction between the
calcium powder and binder. This high solubility of
Sealapex supports our finding of highest release of
calcium and hydrogen ions.
The results of this study strongly suggest
that sealers with high calcium ion release and high
pH values have superior biological properties which
render their use as adequate endodontic sealers to be
used in problem solving in root canal system.
Conclusion:
Based on the methodology employed in this present
study, it can be concluded that:
• MTA Fillapex and Sealapex presents an alkaline
pH and promote calcium releasing at all evaluation
periods;
• MTA Fillapex has a lower pH than Sealapex at all
evaluation periods (p < 0.001);
• Sealapex provided highest calcium release as
compared to MTA Fillapex and Control group (p <
0.001)
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