One of the defining principles of my practice is investing in the correct tools. I never want to cut corners when it comes to the treatment I give my patients, and part of that is staying up-to-date on the tools that are available to me. That means taking advantage of technology like GentleWave, but it also means the simple stuff—like which root canal sealers to use.
There are so many different options out there that it can be hard to figure out what is the best root canal sealer. I wanted to share my two cents on root canal sealers so you can make an educated decision on what to use in your practice.
Root Canal Sealers: The Basics
In dental school I learned that gutta percha doesn’t seal—sealer seals. Root canal sealer is necessary to close the space around your gutta percha all the way to the dentinal wall. Another function of root canal sealer is to fill in any gaps and voids, and to flow into and seal off lateral and accessory canals. Clearly, choosing a good sealer that works in your hand is imperative to your treatments’ success.
Before I share my thoughts on the best root canal sealers, let’s go back to dental school for a moment. Here are the properties of an ideal root canal sealer, as described by Grossman:
- Exhibits tackiness when mixed to provide good adhesion between it and the canal wall when set.
- Establishes a hermetic seal.
- Has radiopacity so that it can be seen on the radiograph.
- Is a very fine powder so it can mix easily with the liquid.
- Doesn’t cause shrinkage on setting.
- Doesn’t cause staining of tooth structure.
- Is bacteriostatic, or at least does not encourage bacterial growth.
- Exhibits a slow set.
- Is insoluble in tissue fluids.
- Is tissue tolerant, that is, non-irritating to periradicular tissue.
- Is soluble in common solvent if it is necessary to remove the root canal filling.
Now, are you ready to hear something crazy?
There is no sealer that has 100% of these properties. Most, if not all, sealers are toxic upon a fresh mix—but the toxicity decreases when it sets. This is why you should avoid over-extrusion of your sealer. (I always love a good sealer puff, but we shouldn’t overdo it!)
Now, let’s take a look at the different types of sealers out there.
My Preferred Root Canal Sealer
There’s a huge variety of root canal sealers available to dentists today. You can find zinc oxide-eugenol sealers, glass ionomer sealers, resin sealers, and bioceramic sealers, but those are just a few of your options. If you’re feeling overwhelmed, it’s no wonder!
Right now, the root canal sealer that I use is AH Plus—an epoxy resin sealer. Specifically, I use Ribbon sealer by Dentsply Sirona, but you can find the same formulation with AH Plus by Dentsply Maillefer. Now, keep in mind that this is different from AH-26, which released formaldehyde while it was setting.
I’ve been using AH Plus/Ribbon for twelve years, and I’ve been very happy with it. I love the way it flows—I’m always sure that it goes into those little voids around my obturation material, and I’ve seen it flow into lateral canals over and over again. It has great adhesion and is radiopaque, which makes my fills look dense and makes it easy to remove if I ever have to retreat my own case. One drawback is that it does shrink upon setting, but overall, I’ve had a great experience using it.
But, just because I use it doesn’t mean you need to run out and make any changes. You might even want to use different sealers in different situations. So, let’s talk about the rest of the best root canal sealers out there so that you can make the most educated decision possible for what to use in your practice.
Other Root Canal Sealers
Dentists have used zinc oxide-eugenol root canal sealers for years, with a lot of success. The major benefit of a zinc oxide sealer is that it will resorb if it has overextended into the periapical tissues. It also exhibits antimicrobial activity; however, it can lead to staining in some tooth structures.
Examples of zinc-oxide based sealers include Roth’s Sealer, Tubliseal, and Pulp Canal Sealer EWT. This sealer’s resorption qualities make it a great choice if the apex of the tooth is close to a vital structure such as the inferior alveolar nerve.
Manufacturers developed calcium hydroxide root canal sealers because they thought they would be able to create antimicrobial activity. Unfortunately, we haven’t seen this effect demonstrated, since the material needs to be soluble in order to release the calcium hydroxide—and that would defeat the purpose of your sealer! This type of sealer also resorbs well over time. An example of a calcium hydroxide sealer would be Sealapex—which is actually the sealer that I became familiar with in dental school many years ago!
Glass ionomer sealers were all the rage when I was an endodontic resident, but this trend has fizzled a bit since then. The main reason why these were so popular back in the day is because of their dentin-bonding properties. Unfortunately, these sealers’ setting properties are questionable at best. They have no antimicrobial activity, and are difficult to remove in case of a retreatment. Ketac-Endo is one example of a glass ionomer sealer.
Bioceramics entered the scene during the 1990s, but their newest generation gives them some good flow. These sealers have become popular because they’ve revived the use of a single cone obturation. Instead of getting a shrinkage of the sealer, you’ll see a slight expansion—around 0.2%. This method means that your gutta percha’s purpose changes—it’s meant to force your sealer into the small crevices, as well as keeping a soft core in the middle in case of a retreatment. In the past, we wanted to have more gutta percha and less sealer in our obturations, but bioceramic sealers necessitate less gutta percha and more sealer.
Once set, they won’t show much resorption, so be careful not to over-extrude your sealer. Another downside to bioceramic root canal sealers is that they make retreatment very difficult—you might need to save a tooth from a surgical retreatment method. The best way to avoid this is to make sure that your disinfection protocol is flawless.
Some bioceramic products will discolor the teeth as well, but newer formulations such as EndoSequence BC Sealer show less discoloration. There are also different versions of these sealers. The new high-flow version can also be used for warm vertical obturation, which I love, since I don’t do a single cone obturation. I like to use this sealer in certain situations, especially when I am dealing with resorption in the middle to apical third of a canal and I want to make sure those areas have a good seal with something that won’t resorb over time.
Which Sealer to Pick?
So, what’s the best root canal sealer to use? The answer is that there’s no perfect sealer out there, and oftentimes you’ll need to choose which one you use based on the case you have in front of you. The sealers I have in my practice are Ribbon epoxy resin sealer and EndoSequence BC Sealer. I use the Ribbon sealer the most, but I adapt when necessary.
As in everything else in the world of endodontics, you’ll probably need to do some experimentation to figure out what the best root canal sealer is for you!
Which sealers have you tried out? Which do you like the best? Let me know in the comments section!