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A great number of bioceramic sealers commercially available nowadays show a great diversity in their biological, chemical, and physical properties. Such differences can also significantly affect clinical performance, and consequently, new commercially available products must be carefully investigated to assess quality and check differences with existing products. The current in vitro study investigated five physicochemical properties (setting time, solubility, pH analysis, radiopacity, and film thickness) of two commercially available bioceramic sealers. The null hypothesis was that the composition of the two products was the same, the manufacturing site was the same and consequently, they should exhibit the same properties when subjected to in vitro tests. Tests were conducted based on the International Standard Organization (ISO) 6876/2012 recommendations. For each test 10 samples for each product were evaluated. All data were recorded and analyzed statistically by ANOVA and Tukey’s test at the 5% significance level. For all tests, no statistically significant differences were found between the two groups. Based on the findings of this study, we may conclude that there is a great similarity in chemical composition and manufacturing or, more likely, the two products, which are made by the same manufacturers, are identical.
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Alberto  de Biase
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Annali di stomatologia
bioceramic
Physicochemical properties of two commercially available bioceramic sealers: An in vitro study
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Original Article
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Alberto  de Biase
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University of Rome La Sapienza, Italy.
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Physicochemical properties of two commercially available bioceramic sealers: An in vitro study
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                                                                                   Original research article


Physicochemical properties of two commercially
available bioceramic sealers: An in vitro study




Tugba Turk1                                              groups. Based on the findings of this study, we may
Luca Piccoli2                                            conclude that there is a great similarity in chemical
Francesca Romana Federici3                               composition and manufacturing or, more likely, the
Ayfer Atav Ates4                                         two products, which are made by the same manufac-
Maurilio D’ Angelo5                                      turers, are identical.
Alberto de Biase6
                                                         Keywords: Root canal, sealer, obturation, bioceramic
1
  University of Smirne, Turkey.                          Copyright. Authors retain copyright of the article
btugbaturk@gmail.com
2
  University of Rome La Sapienza, Italy
luca.piccoli@uniroma1.it                                 Introduction
3
  University of Rome La Sapienza, Italy
f.federici@uniroma1.it                                   Successful endodontic therapy is accomplished by prop-
4
  Istinye University , Istanbul, Turkey.                 er shaping and cleaning procedures followed by three-
carminaayfer@hotmail.com                                 dimensional, hermetic sealing of the root canals with
5
  University of Rome La Sapienza, Italy                  appropriate root canal filling materials (1). Endodontic
mauriliodangelo@uniroma1.it                              filling materials are placed permanently in the root ca-
6
  University of Rome La Sapienza, Italy.                 nal to ensure long-term endodontic success, aiming
alberto.debiase@uniroma1.it                              at avoiding leakage of bacterial invasion by blocking
                                                         the pathways of communication between the root canal
                                                         system and its surrounding tissues (2). For many de-
Corresponding author:                                    cades gutta-percha has been the golden standard and
Maurilio D’Angelo                                        the ideal core material of the filled root canals, being
mauriliodangelo@uniroma1.it                              inert, biocompatible, non-resorbable and thermoplastic
                                                         (1). However, due to the inability of gutta-percha to ad-
                                                         here to dentine, a root canal sealer was also needed
Abstract                                                 to improve sealing, even if sealer was considered the
                                                         weak part of the obturation, being more toxic and re-
A great number of bioceramic sealers commercially        sorbable. Ideally, a sealer should also exhibit alkalinity
available nowadays show a great diversity in their       and bioactive properties to improve tissue healing and
biological, chemical, and physical properties. Such      remineralization. For many years several root canal
differences can also significantly affect clinical       sealers have been commercialized with a great diversi-
performance, and consequently, new commercially          ty in their biological, chemical, and physical properties,
available products must be carefully investigated to     but none of them possessed all the ideal properties de-
assess quality and check differences with existing       scribed by Grossman (3).
products. The current in vitro study investigated five   In recent times endodontics has made huge progress,
physicochemical properties (setting time, solubil-       especially with advancements in nickel-titanium file de-
ity, pH analysis, radiopacity, and film thickness) of    sign and metallurgy (4-6). New operative techniques
two commercially available bioceramic sealers. The       have been developed, focusing on making chemo-
null hypothesis was that the composition of the two      mechanical preparation more rapid and efficient, and
products was the same, the manufacturing site was        ideally increasing quality by providing more predict-
the same and consequently, they should exhibit the       able cleaning and shaping results (7-10). As a conse-
same properties when subjected to in vitro tests.        quence, there has been a similar interest in improving
Tests were conducted based on the International          the simplicity and quality of root canal obturation, with
Standard Organization (ISO) 6876/2012 recommen-          a continuous request for alternative sealers that are
dations. For each test 10 samples for each product       more biocompatible, more bioactive, and more capa-
were evaluated. All data were recorded and ana-          ble of bonding to the root canal wall when compared
lyzed statistically by ANOVA and Tukey’s test at the     to traditional resin-based or eugenol-based sealers
5% significance level. For all tests, no statistically   (11-16). Therefore, the criteria for the ideal material for
significant differences were found between the two       use in endodontic obturations must be comprehensive


10.59987/ads/2023.4.43-48                                                                                              43
     Physicochemical properties of two commercially available bioceramic sealers: An in vitro study

     and include the following characteristics: non-toxic, in-     this process was repeated until the needle no longer in-
     soluble in tissue fluids, dimensionally stable, antibacte-    dented the sealer surface. The final setting time (min)
     rial, hard tissue conductive, biocompatible, radiopaque       was recorded and all data were analyzed statistically by
     and easy to handle (3).  New bioceramic sealers were          ANOVA and Tukey’s test at the 5% significance level.
     developed to fulfill these requests, and in the last de-
     cade, these products have become more widely inves-           Solubility test
     tigated and clinically used worldwide, even if they are
     generally more expensive than traditional sealers (15).       The test was carried out in accordance with the ISO
     However, the various bioceramic sealers commercially          6876/2012 recommendations using 10 samples for each
                                                                   group. Similarly, to the setting time tests gypsum molds
     available nowadays show a great diversity in their bio-
                                                                   with an internal diameter of 10 mm and height of 2 mm
     logical, chemical, and physical properties: most of them
                                                                   were fabricated, then filled with the endodontic sealers
     are mainly related to their chemical composition, but
                                                                   and stored in an incubator (ICT-120 Permax, Treviglio
     also to the manufacturing process. Such differences can
                                                                   Italy) with 95% humidity at 37 °C for 24 hours for set-
     also significantly affect clinical performance, and con-
                                                                   ting. The disc-shaped specimens were then removed
     sequently, new commercially available products must
                                                                   from the mould, and weighed (initial mass = W1) by
     be carefully investigated to assess quality and check
                                                                   using an analytical balance (Mettler-Toledo, model
     differences with existing products (11-13). It has been       AE1633, Novate Milanese, Italy)) with an accuracy of
     shown that the safety data sheets and manufacturer            0.001 g. Then, each specimen was hung using a ny-
     details of currently available bioceramic sealers were        lon thread in a closed plastic fbootle containing 10 mL
     imprecise. Moreover, little detail on composition was         of saline solution and stored again in the incubator for
     provided by manufacturers (11).                               two weeks with the same humidity and temperature de-
     The current in vitro study investigated five physicochem-     scribed above. The specimens were then removed from
     ical properties (setting time, solubility, pH analysis, ra-   the incubator, dried with absorbent paper, and placed in
     diopacity and film thickness) of two commercially avail-      a dehumidifying chamber for 24 hours. After completing
     able bioceramic sealers: a new one and the one which          this procedure the specimens were weighed again (final
     has been most extensively evaluated in the last decade.       mass = W2) and the material loss was calculated as a
     The null hypothesis was that they should exhibit the          percentage of the difference in weight by the following
     same properties when subjected to in vitro tests, be-         formula: (w1-w2) /w1 x100. All data were analyzed
     cause manufacturing site and process are the same.            statistically by ANOVA and Tukey’s test at the 5% sig-
                                                                   nificance level.
     Materials and methods
     For each group and for each test 2 samples were taken
                                                                   PH analysis
     from a different package. Overall 5 packages of Endo-         The test was carried out using 10 specimens for each
     sequence BC sealer (BUSA/Brasseler USA. Savannah,             group. Each sample of root canal sealer was inserted
     GA) and 5 packages of Edge Bioceramic (EdgeEndo,              into polytetrafluoroethylene tubes to obtain discs with
     Albuquerque, New Mexico, USA) were used. Sample               a 5 mm diameter and 2 mm thickness. After the sealer
     size was determined by Power Analysis and for each            setting in an incubator (ICT-120 Permax, Treviglio Italy
     test it was calculated based on a power of 80% and a          ) with 95% humidity at 37 °C. for 24 hours, each speci-
     0.05 alpha type error (G*Power, Heinrich-Heine-Univer-        men was immersed into a closed flask containing 10 mL
     sität Düsseldorf, Düsseldorf, Germany). For each group,       of distilled water at an initial pH of 7 and a temperature
     the indicated sample size was 10. All samples were            of 25 °C. Then the specimens were stored again in an
     analyzed before the expiration dates established by the       incubator at 37 °C and 95% relative humidity for 7 (?).
     manufacturers.                                                The calibration of the pH meter (Jen-way 3510 bench
                                                                   pH meter, UK) was performed with a standard solution at
     Setting time.                                                 pH 4.0 and 7.0 at a constant temperature of 25 °C. The
                                                                   pH of the solution was measured after 24 hours. All data
     Setting time was evaluated based on the International         were recorded and analyzed statistically by ANOVA and
     Standard Organization (ISO) 6876/2012 recommenda-             Tukey’s test at the 5% significance level.
     tions, with a slight change. Gypsum molds to measure
     the setting time of the bioceramic sealers instead of the     Radiopacity
     recommended stainless steel ones were selected. This
     choice was performed to avoid any risk of incomplete          The test was performed following the recommendation
     setting related to the mold because gypsum contains           described in ISO 6876/2012. For each group, each of
     water and bioceramic sealers require moisture for set-        the five packages was used to make two disc-shaped
     ting, whilst stainless steel does not contain water. For      specimens (10 x 1 mm). Overall, ten specimens for each
     each group, each of the five packages was used to fill        group were tested. After setting the materials in an in-
     two molds. Overall, ten specimens for each group were         cubator (ICT-120 Permax, Treviglio Italy) with 95% hu-
     tested and stored in an incubator (ICT-120 Permax,            midity at 37 °C. for 24 hours, radiographs were taken
     Treviglio Italy) with 95% humidity at 37 °C. The setting      using periapical digital film (Digora, Dexis) including a
     time was measured using a Gilmore needle, with a total        graduated aluminum step wedge varying from 2 to 16
     weight of 100 g and a flat end of diameter 2.0 mm, start-     mm in thickness for comparison. The dental X-ray unit
     ing 1 h before the setting time specified by the manu-        (Kodak) was set at 70 kVp, 10 mA, and a distance of 50
     facturer, and was repeated every 5 minutes. The needle        cm. The radiopacity of sealers was compared to that of
     was carefully placed vertically against the sealer and if     the aluminum step wedge using VIXWIN-2000 software.
     an indentation was visible it was raised to clean, and        All data (mmAl) were recorded and analyzed statistically


44                                                                                                   10.59987/ads/2023.4.43-48
Tugba Turk et al.

by ANOVA and Tukey’s test at the 5% significance level.              affect the clinical performance of these materials and
Film thickness                                                       highlighted the importance of using reputable materials
Tests were performed according to the ISO 6876/2012                  that have been adequately researched both in vitro and
recommendations. Initially, the total thickness of two piec-         in clinical practice (11).
es of flat glass plates (5 mm in thickness, 200 × 10 mm              Results from the present study showed that in all the in
surface area) placed over one another was measured                   vitro physical and chemical tests performed there was
(TH1) using an electronic digital caliper (ELE Digital Cali-         no statistically significant difference between the two
per, Atessa, Italy). Each glass was also weighted with               groups. This could be explained by a great similarity in
an analytical balance (Adam Equipment 4-digit precision              manufacturing or, more likely, the two products, which are
weighing balance, UK) with an accuracy of 0.001 g. For               made by the same manufacturers, are identical. EndoSe-
each group, 10 samples of sealer were collected from                 quence BC sealer could also be considered as a control
the syringe transferred immediately onto the lower glass             because of its reputation as a gold standard for studies
plate and covered by the upper glass plate. The weight               on bioceramic sealers. It is one of the very first commer-
glasses with sealer were measured again to ensure a                  cial products and has been subjected in recent years to
similar amount of sealer (0,05 ml) in all specimens, and             many in vitro and vivo researches, which provided excel-
specimens were put into an incubator with a 150 N load               lent results, and currently it is the bioceramic sealer most
weight vertically applied for 3 minutes on the upper glass           widely investigated in dental literature and most validated
plate. After 10 minutes the total thickness (TH2)of the              for clinical use (16-24). On the contrary no studies are
plates, including the sealer, was measured again using               available concerning Edge Bioceramic sealer.
the same digital caliper, and the amount of the film thick-          Setting time was similar between the two products,
ness (μm )was obtained by subtracting the initial mea-               which are both available in premixed syringes inside
surement of the two glasses from final total thickness of            which inorganic components of the sealers (calcium
the glass plates ( TH2-TH1) All data were recorded and               phosphate, silicates) are premixed with water-free thick-
analyzed statistically by ANOVA and Tukey’s test at the              ening vehicles. This formulation enables the sealer to be
5% significance level.                                               delivered in the form of a premixed paste, and water/
                                                                     moisture is required for the setting reaction. This is a
                                                                     very user-friendly way of applying the sealer into canals
Results                                                              and also avoids poor performance related to incorrect
Results are shown in Table 1. Mean values, standard                  mixing of the sealers. In a clinical environment, the set-
deviation, and significance are shown for each of the fol-           ting reaction can be also catalyzed by the presence of
lowing five in vitro tests: setting time, solubility, pH analy-      moisture in dentinal tubules and be completed in a few
sis, radiopacity, and film thickness. Mean values for the            hours, even if it could be longer in particularly dried ca-
setting time (min) were 90,25 and 86,77, respectively for            nals. Therefore, the amount of moisture present in the
BC Endosequence and Edge Bioceramic. Mean values                     dentinal tubules of the canal walls and, consequently,
for the solubility test (%) were 3,4 and 3,6, respectively           the setting time could also be affected by differences in
for BC Endosequence and Edge Bioceramic. Mean val-                   the absorption with paper points. On the contrary, too
ues for PH were 10,8 and 10,9 respectively for BC En-                much water left inside canals could decrease the micro-
dosequence and Edge Bioceramic. Mean values for the                  hardness of the material.
radiopacity (mmAl) were 3,25 and 3,6, respectively for               In the present study, the solubility of both products was
BC Endosequence and Edge Bioceramic. Mean values                     slightly higher than the minimum ISO standard value,
for the film thickness (μm) were 48 and 45, respective-              with no statistically significant differences between the
ly for BC Endosequence and Edge Bioceramic For all                   two groups. Such high values could be attributed to seal-
tests, no statistically significant differences were found           ers’ hydrophilic nanosized particles, which have a posi-
between the two groups.                                              tive effect on film thickness and flowability but could also
                                                                     increase their surface area and allow more liquid mol-
                                                                     ecules to come into contact with the sealer and conse-
Discussion
                                                                     quently increase its solubility. These results are in accor-
Bioceramic sealers have shown more favorable proper-                 dance with previous studies on bioceramic sealers, but
ties when compared to traditional sealers, documented                they also conflict with other studies that demonstrated
by many in vitro and in vivo studies (17-24). These stud-            that the solubility of Endosequence BC sealer was con-
ies have also shown significant differences amongst                  sistent with ISO standards (23). Such different findings
currently available bioceramic sealers (17-24 ). In a re-            could be related to variations in the test methods (24);
cent review, authors showed that in the last years, en-              more precisely variations in the procedure used to dry
dodontists faced a rapid increase in materials identified            samples may result in significant differences. Another
as bioceramics on the market, but these materials have               important factor is the time between mixing the sealer
different chemistries, and some of the constituents are              and immersion in the storage solution. In some stud-
not declared (11). The authors conclude that this may                ies, mixed sealers were immersed after 150% or 300%




 Table1                SettingT time (min)    Solubility test (%)   PH analysis     Radiopacity (mmAl)     Film thickness (μm)

 BC Endosequence 90,25 +/- 12,5               3,4 +/-0,4            10,8 +/- 0,25   3,25. +/- 0,25         48 +/- 0,1
 Edge Bioceramic 86,75 +/- 11,5               3,6 +/-0,5            10,9 +/- 0,25   3,6 +/- 0,5            45 +/- 0,2
                       NS                     NS                    NS              NS                     NS



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     Physicochemical properties of two commercially available bioceramic sealers: An in vitro study

     of their setting time compared with 300% whilst others
     used a set duration of 24 h after mixing. It is noticeable      1.    Pirani C, Camilleri J. Effectiveness of root canal filling ma-
     that the reported solubility values were inversely relat-             terials and techniques for treatment of apical periodonti-
                                                                           tis: A systematic review. Int Endod J. 2023 Oct;56 Suppl
     ed to the duration between mixing and immersion (24)
                                                                           3:436-454. doi: 10.1111/iej.13787. Epub 2022 Jul 5. PMID:
     Both sealers showed a strong alkaline pH after 24                     35735776.
     hours, with no significant differences between the two          2.    Gambarini, G.; Testarelli, L.; Pongione, G.; Gerosa, R.;
     groups. This is a positive finding because it can deter-              Gagliani, M. Radiographic and Rheological Properties of
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     fect that eliminates the residual bacteria that survived
                                                                           Leon-Oliva D, Barrena-Blázquez S, Pereda-Cerquella C,
     after chemo-mechanical canal preparation. An alkaline                 Garrido-Gil MJ, Manteca L, Bujan J, García-Honduvilla N,
     pH may also contribute to enhanced osteogenic poten-                  García-Montero C, Rios-Parra A. Bioceramic versus tradi-
     tial by activating alkaline phosphatase, neutralizing lac-            tional biomaterials for endodontic sealers according to the
     tic acid from osteoclast, and allowing tissue repair with             ideal properties. Histol Histopathol. 2023 Sep 8:18664.
     the formation of hydroxyapatite. An alkaline PH is also               Doi 10.14670/HH-18-664. Epub ahead of print. PMID:
                                                                           37747049.
     related to improved biocompatibility. PH data from the
                                                                     4.    Gambarini G, Miccoli G, Seracchiani M, Khrenova T, Don-
     present study are similar to values obtained in other                 francesco O ;Angelo M, Galli M, Di Nardo D, Testarelli L.
     studies which analyzed EndoSequence BC sealer (25).                   Role of the Flat-Designed Surface in Improving the Cyclic
     Radiopacity of root canal obturation materials is a fun-              Fatigue Resistance of Endodontic NiTi Rotary Instruments.
     damental physical property that allows radiographic                   Materials (Basel). 2019 Aug 8;12(16):2523. doi: 10.3390/
     evaluation of the root canal filling. In clinical practice,           ma12162523. PMID: 31398814; PMCID: PMC6720207.
                                                                     5.    Plotino G, Grande NM, Testarelli L, Gambarini G, Cast-
     the quality of the filling is checked by radiographs im-
                                                                           agnola R, Rossetti A, Özyürek. Gambarini G, Miccoli G,
     mediately after obturation. Single-cone hydraulic con-                Seracchiani M, Khrenova T, Donfrancesco O; Angelo M,
     densation with bioceramics allows to verify if overfilling            Galli M, Di Nardo D, Testarelli L. Role of the Flat-Designed
     or underfilling is present, and if needed clinicians can              Surface in Improving the Cyclic Fatigue Resistance of End-
     modify the obturation by adding more sealer of placing                odontic NiTi Rotary Instruments. Materials (Basel). 2019
     the gutta-percha cone more apically or coronally, due                 Aug 8;12(16):2523. doi: 10.3390/ma12162523. PMID:
                                                                           31398814; PMCID: PMC6720207.
     to an adequate setting time of the sealer. An ideal
                                                                     6     Zanza, A.; D’Angelo, M.; Reda, R.; Gambarini, G.; Testarelli,
     material should be clearly visible inside and outside the             L.; Nardo, D. D. An Update on Nickel-Titanium Rotary In-
     canal,also to detect overextension ( a moderate one is                struments in Endodontics: Mechanical Characteristics,
     usually tolerated by tissue due to the biocompatibility               Testing and Future Perspective—An Overview. Bioengi-
     of the bioceramic sealer ) and its possible resorption                neering 2021, 8 (12), 218. https://doi.org/10.3390/bioengi-
     over time. In the present study, the radiopacity test was             neering8120218.
                                                                     7.    Ali, A.; Bhosale, A.; Pawar, S.; Kakti, A.; Bichpuriya, A.;
     performed following ISO 6876/2001 recommendations,
                                                                           Agwan, M. A.; Agwan, A. S. Current Trends in Root Canal
     using aluminum as the control material. Both products                 Irrigation. Cureus 2022, 14 (5), e24833. https://doi.org/
     showed higher values compared to the ISO minimal re-                  10.7759/cureus.24833
     quirements (radiopacity equivalent to 3 mm thick), but          8.    Li, Q.; Zhang, Q.; Zou, X.; Yue, L. Evaluation of Four Final
     there were no statistically significant differences be-               Irrigation Protocols for Cleaning Root Canal Walls. Int. J.
     tween the two groups. For both products film thickness                Oral Sci. 2020, 12 (1), 29. https://doi.org/10.1038/s41368-
                                                                           020-00091-4.
     was in accordance with ISO minimal requirements and
                                                                     9.    Plotino, G.; Grande, N. M.; Mercade, M.; Cortese, T.; Staf-
     in accordance with other published studies for EndoSe-                foli, S.; Gambarini, G.; Testarelli, L. Efficacy of Sonic and
     quence BC sealer (25)                                                 Ultrasonic Irrigation Devices in the Removal of Debris from
                                                                           Canal Irregularities in Artificial Root Canals. J. Appl. Oral
                                                                           Sci. 2019, 27, e20180045. https://doi.org/10.1590/1678-
     Conclusions
                                                                           7757-2018-0045
     The present in vitro study investigated five physicochem-       10.   Plotino, G.; Grande, N. M.; Tocci, L.; Testarelli, L.; Gam-
     ical properties (setting time, solubility, pH analysis, radi-         barini, G. Influence of Different Apical Preparations on Root
                                                                           Canal Cleanliness in Human Molars: A SEM Study. J. Oral
     opacity, and film thickness) of two commercially avail-               Maxillofac. Res. 2014, 5 (2), e4. https://doi.org/10.5037/
     able bioceramic sealers: BC EndoSequence and Edge                     jomr.2014.5204
     Bioceramic. Based on the findings of this study, which          11.   Cardinali F, Camilleri J. A critical review of the material prop-
     showed no statistically significant differences in all tests          erties guiding the clinician’s choice of root canal sealers.
     between the two products we may conclude that there                   Clin Oral Investig. 2023 Aug;27(8):4147-4155. doi: 10.1007/
     is a great similarity in manufacturing or, more likely, the           s00784-023-05140-w. Epub 2023 Jul 17. PMID: 37460901;
                                                                           PMCID: PMC10415471.
     two products, which are made by the same manufactur-            12.   Dong X, Xu X. Bioceramics in Endodontics: Updates and
     ers, are identical.                                                   Future Perspectives. Bioengineering (Basel). 2023 Mar
                                                                           13;10(3):354. doi: 10.3390/bioengineering10030354. PMID:
     Declaration of competing interest                                     36978746; PMCID: PMC10045528.
     The authors have no conflict of interest relevant to this       13.   Hamdy, T.M., Galal, M.M., Ismail, A.G. et al. Physicochemi-
     article.                                                              cal properties of AH plus bioceramic sealer, Bio-C Sealer,
                                                                           and ADseal root canal sealer. Head Face Med 20, 2
                                                                           (2024). https://doi.org/10.1186/s13005-023-00403-z
     Acknowledgments                                                 14.   Kwak SW, Koo J, Song M, Jang IH, Gambarini G, Kim HC.
     There was no funding related to this study.                           Physicochemical Properties and Biocompatibility of Various
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