Can Radiotherapy Affect the Apical Sealing

Ability of Resin-Based Root Canal Sealers?

Emre Bodrumlu, Aysun Avsar, Ahmet Deniz
Meydan and Nuray Tuloglu
J Am Dent Assoc 2009;140;326-330

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Can radiotherapy affect the apical sealing

ability of resin-based root canal sealers?
Emre Bodrumlu, DDS, PhD; Aysun Avsar, DDS, PhD; Ahmet Deniz Meydan, DDS, PhD;
Nuray Tuloglu, DDS

ABSTRACT
Background. The authors conducted a study to assess the influence of radiotherapy on the apical sealing ability of one recently introduced resin-based
root canal sealer and two sealers that have been in use for several years.
Methods. The authors divided 90 human maxillary anterior teeth into three
groups according to the type of root canal sealer used and, using lateral condensation, obturated the roots with gutta-percha. They randomly divided all
roots into two main groups according to the presence or absence of radiotherapy. For the groups that received irradiation, a dose of 60 gray was delivered in fractions of 1.8 Gy per day, five days a week for seven weeks. The
authors then performed the centrifuging dye penetration test to determine
apical leakage for each specimen.
Results. The authors compared the specimens in the groups that received
radiotherapy after endodontic treatment with the specimens in the groups
that did not undergo radiotherapy after endodontic treatment. They found
that mean apical leakage was slightly higher in the radiotherapy groups, but
they did not observe any statistical difference between the groups (P > .05). In
the groups that did not undergo radiotherapy, the mean apical leakage for the
specimens in the MM-Seal (MicroMega, Besanon, France [not marketed in
the United States]), AH Plus (Dentsply DeTrey GmbH, Konstanz, Germany)
and AH 26 (Dentsply DeTrey GmbH) groups was 2.52 0.42 millimeters,
2.85 0.52 mm and 3.73 0.41 mm, respectively. In the groups that underwent radiotherapy, the mean apical leakage for the specimens in the
MM-Seal, AH Plus and AH 26 groups was 2.72 0.55 mm, 2.96 0.47 mm
and 3.93 0.61 mm, respectively.
Conclusion. The apical sealing ability of the resin-based root canal sealers
decreased slightly when radiotherapy was administered, although there was
no statistically significant difference.
Clinical Implications. Clinicians can safely use a resin-based root canal
sealer in patients receiving radiotherapy.
Key Words. Resin-based root canal sealer; apical sealing ability;
radiotherapy.
JADA 2009;140(3):326-330.

Dr. Bodrumlu is an assistant professor, Department of Operative Dentistry and Endodontics, Ondokuz Mayis University, Faculty of Dentistry,
55139 Kurupelit-Samsun, Turkey, e-mail bodrumlu@omu.edu.tr. Address reprint requests to Dr. Bodrumlu.
Dr. Avsar is an assistant professor, Department of Pediatric Dentistry, Faculty of Dentistry, Ondokuz Mayis University, Kurupelit-Samsun, Turkey.
Dr. Meydan is an assistant professor, Department of Radiation Oncology, Ondokuz Mayis University, Kurupelit-Samsun, Turkey.
Dr. Tuloglu is a research assistant, Department of Pediatric Dentistry, Faculty of Dentistry, Ondokuz Mayis University, Kurupelit-Samsun, Turkey.

326

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he goal of endodontic
therapy is to clean
and disinfect the root
canal system, as well
as to seal all portals
of entry to prevent reinfection.
Consequently, root canal filling
materials should create a hermetic seal between the root
canal system and the periapical
tissues. Apical leakage is a
common cause of clinical failure
of root canal treatment.1,2 Therefore, microleakage studies of the
sealing properties of endodontic
materials are important.2
The number of patients with
cancer has been increasing
steadily, and these patients may
require endodontic treatment.
Radiotherapy can result in side
effects on dental hard tissues.
Researchers have observed a
significant reduction in dentin
microhardness after irradiation.3,4 Moreover, irradiation
may affect the bond strength
between dental adhesives and
dentin.5 Nevertheless, the effects
of radiotherapy on the sealing
ability of root canal filling
materials is not known.
Although a wide variety of
root canal filling materials are

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327

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available commercially, clinicians generally

removed the smear layer by washing the roots in
prefer the resin-based root canal sealers. MM10 mL of 17 percent ethylenediaminetetraacetic
Seal (MicroMega, Besanon, France [not maracid (Canal+, Septodont, Saint-Maur des Fosss,
keted in the United States]) is a recently introFrance) for five minutes, followed by 10 mL of
duced resin-based root canal sealer. It is
5.25 percent NaOCl. Finally, we flushed the root
canals with 3 mL of saline solution and dried
composed of epoxy polymer resin, ethylene glycol
them with paper points.
salicylate, calcium phosphate, bismuth subcarRoot canal obturation. We filled the roots
bonate and oxide components. However, to our
with gutta-percha by using the lateral condensaknowledge, no data are available concerning its
tion technique with one of the following sealers
sealing ability in comparison with that of other
(n = 30 per group): MM-Seal, AH 26 and AH
sealers. Moreover, no information has been pubPlus. We prepared the sealers according to the
lished about the apical sealing ability of any
manufacturers instructions. After the obturation
sealer after radiotherapy.
process, we removed excess gutta-percha and
The purpose of this study was to assess the
filled the coronal access cavities with temporary
influence of radiotherapy on the apical sealing
filling material (Cavit G, 3M ESPE AG, Seefeld,
ability of one recently introduced resin-based
Germany). We stored the specimens for three
root canal sealer and two resin-based root canal
weeks in 100 percent relative
sealers that have been in use for
humidity at 37C to allow the
several years: MM-Seal, AH 26
Although a wide
sealers to set.
(Dentsply DeTrey GmbH, Konvariety of root canal
We randomly divided all 90
stanz, Germany) and AH Plus
roots into two main groups
(Dentsply DeTrey, GmbH).
filling materials
according to the presence or
are available
MATERIALS AND METHODS
absence of radiotherapy.
commercially,
Radiotherapy. A radiation
We selected 90 extracted human
clinicians generally
therapist in the Department of
maxillary anterior teeth (plus six
prefer the
Radiation Oncology, Faculty of
teeth to be used as positive controls
resin-based
root
Medicine, Ondokuz Mayis Univerand six teeth to be used as negative
sity, delivered radiation to specicontrols) with straight root canals
canal sealers.
mens. The therapist placed the
and fully mature root apexes,
roots, which were in resin blocks, in
cleaned of extraneous soft tissue
a 25-square-centimeter plastic container during
and calculus. We obtained ethical approval for
irradiation. To administer a consistent radiation
use of the extracted teeth from the ethical comdose, the therapist replaced the saline solution
mittee at Ondokuz Mayis University, Kurupelitdaily to a level up to 0.5 cm above the resin
Samsun, Turkey. One of us (N.T.) removed the
blocks in the plastic container.3 The radiation
crowns at the cementoenamel junction with a
diamond disk under water coolant. We stored the
therapist administered radiation with Co-60 phoroots in deionized water until use.
tons (Theratron 780C, Theratronics Int., CarRoot canal preparation. Three of us (E.B.,
rollton, Texas) by using a single anterior field.
A.A., N.T.) established the canal lengths visually
The source water surface distance was 80 cm.
by placing a size 15 K-file into each root canal
The therapist delivered a total dose of 60 gray in
until the tip of the file was visible at the tip of
fractions of 1.8 Gy/day (conventional fractionathe apical foramen. We also measured the
tion schedule) five days a week for seven weeks.
working length radiographically and verified the
After irradiation, we again stored both the irradiapical patency. We established working lengths
ated and nonirradiated specimens in saline.
1.0 millimeter short of the apical foramen.
We then coated the roots completely with two
We instrumented the root canals to the
layers of nail varnish, except for the apical parts.
working length with a size 40 K-file by using a
In addition to the 90 roots, we used six roots as
step-back technique. The coronal one-third of the
negative controls (filled with gutta-percha and
roots were flared by using sizes 2, 3 and 4 Gatessealant) and six roots as positive controls (filled
Glidden burs and a slow-speed handpiece. We
with gutta-percha only). We removed the apexes
then irrigated the root canals with 10 milliliters
ABBREVIATION KEY. NaOCl: Sodium hypochlorite.
of 5.25 percent sodium hypochlorite (NaOCl). We

R E S E A R C H

was slightly higher in the radiotherapy

groups, but we did not observe any staMean apical leakage for roots in
tistical difference between the groups
experimental groups.
(P > .05).
SEALER
MEAN ( SD*) APICAL LEAKAGE, mm
P VALUE
For specimens that did not receive
Nonradiotherapy
Radiotherapy
radiotherapy, we found no statistically
Groups
Groups
significant differences between the AH

MM-Seal
2.52 0.42
2.72 0.55
Plus and MM-Seal groups (P > .05).
> .05
AH Plus
2.85 0.52
2.96 0.47
However, the mean leakage values for
AH 26
3.73 0.41
3.93 0.61
the AH Plus and MM-Seal groups were
* SD: Standard deviation.
significantly different from the mean
mm: Millimeters.
leakage value for the AH 26 group
MM-Seal is manufactured by MicroMega, Besanon, France.
AH Plus and AH 26 are manufactured by Dentsply DeTrey GmbH, Konstanz, Germany.
(P < .05).
For specimens that received radioof the roots down to the root canal filling or, in
therapy, we found no statistically significant difthe case of the positive controls, to the point at
ferences between the AH Plus and MM-Seal
which the canal lumen was visible. We coated the
groups (P > .05). However, the mean leakage
negative controls completely with
value for the AH 26 group was stathe nail varnish. We immersed the
tistically different from values for
We used methylene
specimens in 5 percent methylene
the AH Plus and MM-Seal groups
blue dye and centrifuged them at
(P < .05).
blue as the leakage
30 gauss for four minutes. The final
marker because it
DISCUSSION
step was to wash the specimens
has a low molecular
with water.
Radiotherapy involves the delivery
weight and
We grooved the roots longitudiof the correct radiation dose to the
penetrates more
nally on both sides by using a diatumor mass. Absorbed radiation
mond disk under water coolant. We deeply along the root doses are expressed in gray, the
then sectioned them carefully and
standard unit.6 The wide range of
canal filling.
examined each half of each root
side effects of ionizing radiation to
under a stereomicroscope. We
the head and neck region are wellmeasured the amount of leakage
known, and they are related to
from each half, from the apex to the most coronal
cumulative doses that vary from 50 to 70 Gy
section of the root canal to which the dye had
delivered across a five- to seven-week period.
penetrated. We then calculated the mean amount
However, in our study, the specimens were irraof leakage for each of the three sealers.
diated with 60 Gy delivered incrementally across
We used two-way analysis of variance to deterseven weeks,3 which corresponds to a common
mine statistically significant differences in apical
clinical procedure for adults receiving
leakage between the groups. We performed mulradiotherapy.
tiple comparisons by using the t test to isolate
In this study, we stored the freshly extracted
and compare statistically significant differences.
teeth in saline. This is a common procedure, as it
We set the level of significance at = .05.
does not influence the chemical and physical
properties of human tooth structure.
RESULTS
Leakage studies. Leakage studies of the
The table shows the mean ( standard deviasealing properties of endodontic materials are
tion) apical leakage values for specimens in all
important and relevant.7 Different methods have
of the groups. The positive controls exhibited
been used to evaluate the sealing efficacy of
dye penetration along the entire length of the
endodontic cements. We used methylene blue as
root canal, while the negative controls exhibited
the leakage marker because it has a low molecno leakage.
ular weight and penetrates more deeply along
When we compared the groups that received
the root canal filling.8,9
radiotherapy after root canal treatment with the
Air trapped in the root canal filling material or
groups that did not receive radiotherapy after
inside the root canal system may inhibit penetraroot canal treatment, the mean apical leakage
tion of the dye into the pores and gaps.10 Oliver

TABLE

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and the collagen matrix resulting from irradiation do not influence the bond strength of resinbased materials.19,20 For these reasons, the
bonding ability of the sealers in this study was
not affected by radiation therapy, and we
observed no difference in leakage between specimens in the irradiation and nonirradiation
groups.
CONCLUSION

Further studies are needed to assess the sealing

ability of the new root canal sealer, MM-Seal,
and evaluate its clinical performance. In addition, the results of our study show that the apical
sealing ability of the three resin-based root canal
sealers was slightly lower in the groups that
received radiotherapy than in those that did not,
although the differences between the groups
were not statistically significant.
Disclosure. None of the authors reported any disclosures.
1. Verissimo DM, do Vale MS. Methodologies for assessment of
apical and coronal leakage of endodontic filling materials: a critical
review. J Oral Sci 2006;48(3):93-98.
2. Ruddle CJ. Nonsurgical endodontic retreatment. J Calif Dent
Assoc 2004;32(6):474-484.
3. Kielbassa AM, Beetz I, Schendera A, Hellwig E. Irradiation effects
on microhardness of fluoridated and non-fluoridated bovine dentin.
Eur J Oral Sci 1997;105(5 pt 1):444-447.
4. Kielbassa AM, Munz I, Bruggmoser G, Schulte-Mnting J. Effect
of demineralization and remineralization on microhardness of irradiated dentin. J Clin Dent 2002;13(3):104-110.
5. Cheung DT, Perelman N, Tong D, Nimni ME. The effect of
gamma-irradiation on collagen molecules, isolated alpha-chains, and
crosslinked native fibers. J Biomed Mater Res 1990;24(5):581-589.
6. Howard H, Speizer FE. Specific environmental and occupation
hazards. In: Braunwald E, Fausi AS, Kasper DL, et al, eds. Harrisons
Principles of Internal Medicine. 15th ed. Vol. 2, part 15, section 1.395.
New York City: McGraw-Hill; 2001:2591-2592.
7. Miletic I, Ribaric SP, Karlovic Z, Jukic S, Bosnjak A, Anic I.
Apical leakage of five root canal sealers after one year of storage. J
Endod 2002;28(6):431-432.
8. Schafer E, Olthoff G. Effect of three different sealers on the
sealing ability of both thermafil obturators and cold laterally compacted gutta-percha. J Endod 2002;28(9):638.
9. Ahlberg KM, Assavanop P, Tay WM. A comparison of the apical
dye penetration patterns shown by methylene blue and India ink in
root-filled teeth. Int Endod J 1995;28(1):30-34.
10. Oliver CM, Abbott PV. Entrapped air and its effects on dye penetration of voids. Endod Dent Traumatol 1991;7(3):135-138.
11. Pommel L, About I, Pashley D, Camps J. Apical leakage of four
endodontic sealers. J Endod 2003;29(3):208-210.
12. Adanir N, Cobankara FK, Belli S. Sealing properties of different
resin-based root canal sealers. J Biomed Mater Res B Appl Biomater
2006;77(1):1-4.
13. Zmener O, Spielberg C, Lamberghini F, Rucci M. Sealing properties of a new epoxy resin-based root canal sealer. Int Endod J 1997;
30(5):332-334.
14. Bodrumlu E, Tunga U. Apical leakage of Resilon obturation
material. J Contemp Dent Pract 2006;7(4):45-52.
15. Miletic I, Anic I, Pezelj-Ribaric S, Jukic S. Leakage of five root
canal sealers. Int Endod J 1999;32(5):415-418.
16. Sen BH, Pikin B, Baran N. The effect of tubular penetration of
root canal sealers on dye microleakage. Int Endod J 1996;29(1):23-28.
17. Cergneux M, Ciucchi B, Dietschi JM, Holz J. The influence of the
smear layer on the sealing ability of canal obturation. Int Endod J
1987;20(5):228-232.
18. al-Nawas B, Grtz KA, Rose E, Duschner H, Kann P, Wagner W.

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and Abbott10 stated that after centrifugation at

3,000 revolutions per minute for five minutes,
dye penetration was 91.7 percent, while dye penetration via passive immersion was 20.7 percent.
For this reason, these authors10 recommended
use of active dye penetration tests, whereby
trapped air is removed under a vacuum or dye
penetration is performed under high pressure.
We used centrifugation in this study.
A wide variety of root canal sealers are available commercially. Among the resin-based
sealers, the sealing properties of AH Plus and
AH 26 are well-known.11-13 Thus, we compared
their leakage values with those of MM-Seal. In
addition, the sealing ability of these sealers in
patients undergoing radiotherapy had not been
assessed before our study.
Zmener and colleagues13 and Bodrumlu and
Tunga14 reported that the mean apical leakage
value for specimens sealed with AH Plus was
lower than that for specimens sealed with AH 26.
Although we found similar results in this study,
the mean apical leakage values for AH 26 and
AH Plus were lower in the previous studies than
in this study, because they did not use centrifugation to perform the dye penetration tests (thus,
less dye penetrated the roots).
The apical sealing ability of MM-Seal was similar to that of AH Plus. Because no study to date
has evaluated the sealing ability of MM-Seal, we
could not conduct any comparisons. In addition,
regardless of whether the specimens were irradiated or not, MM-Seal and AH Plus were similar
with regard to mean leakage values; this might
be explained by the sealers chemical
components.
The failure of sealers may be the result of
their physical properties (adhesiveness, dimensional stability, flow, solubility).13,15 Some
authors16,17 have suggested that the apical seal
may be improved by increasing the surface
contact between the root canal walls and the
sealer (these connections can be affected by
radiotherapy).
Bond strength. al-Nawas and colleagues18
found that the mechanical properties of dentin
seem to be much less affected by irradiation than
are those of enamel. According to these authors,
irradiation has only a minor effect on the
mechanical properties of dentin. Gernhardt and
colleagues19,20 found no differences between irradiated and nonirradiated dentin specimens.
Changes in hardness, the crystalline structure

R E S E A R C H

Using ultrasound transmission velocity to analyse the mechanical

properties of teeth after in vitro, in situ, and in vivo irradiation. Clin
Oral Investig 2000;4(3):168-172.
19. Gernhardt CR, Koravu T, Gerlach R, Schaller HG. The influence
of dentin adhesives on the demineralization of irradiated and non-

irradiated human root dentin. Oper Dent 2004;29(4):454-461.

20. Gernhardt CR, Kielbassa AM, Hahn P, Schaller HG. Tensile
bond strengths of four different dentin adhesives on irradiated and
non-irradiated human dentin in vitro. J Oral Rehabil 2001;28(9):
814-820.

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