Narrative Review

Tricalcium silicate cement sealers

Do the potential benefits of bioactivity justify the
drawbacks?
Anita Aminoshariae, DDS, MS; Carolyn Primus, PhD; James C. Kulild, DDS, MS

ABSTRACT

Background. Grossman described the ideal properties of root canal sealers. The International
Organization for Standardization and American National Standards Institute and American Dental
Association have codified some of his requirements in ISO 6876 and ANSI/ADA 57, respectively.
In this narrative review, the authors combined the ideal Grossman properties and requirements of
these standards, emphasizing the newer tricalcium silicate cement sealers. This chemical matrix for
such sealers was developed on the basis of the success of bioactive mineral trioxide aggregateetype
(tricalcium silicate cement) materials for enhanced sealing and bioactivity.
Methods. The authors searched the internet and databases using Medical Subject Heading terms
and then conducted a narrative review of those articles involving the tricalcium silicate cement
endodontic sealers.
Results. Ninety-four articles were identified that discussed tricalcium silicate cement sealers. Tri-
calcium silicate cement sealers are partially antimicrobial and have bioactivity, which may presage
improved biological sealing of the root canal system. Most other properties of tricalcium silicate
cement sealers are comparable with traditional root canal sealers.
Conclusions. Within the limitations of this review, tricalcium silicate cement endodontic sealers
met many of the criteria for ideal properties, such as placement, antimicrobial properties, and
bioactivity, but limitations were noted in solubility, dimensional stability (shrinkage and expan-
sion), and retrievability.
Practical Implications. Tricalcium silicateebased cements have been commercialized as bioac-
tive, bioceramic endodontic sealers. Warm, cold, and single-cone obturation techniques are usable,
depending on the commercial product. Some sealers can cause discoloration and are not easily
retrievable, particularly when used to completely obturate a canal.
Key Words. Endodontic sealer; bioactive sealers; tricalcium silicates; bioceramics; Grossman
criteria; ISO 6876; calcium silicate sealers; endodontics; physicochemical properties; root canal
sealer.
JADA 2022:153(8):750-760
https://doi.org/10.1016/j.adaj.2022.01.004

T
he ideal clinical properties of endodontic sealers were well described by Grossman, who in
1940 identified criteria on the basis of the available powder and liquid systems of his era. His
“requirements” were similar to those of Brownlee in 19001 (Table 1). Endodontic sealer
chemistries have progressed from zinc oxideeeugenol to include silicone, epoxy resin, and trical-
cium silicate cementebased sealers.2 Tricalcium silicate cements have contributed substantially to
surgical endodontics3,4 and perforation repair. The advantages of this cement material, originally
known as mineral trioxide aggregate (MTA),5 include better biocompatibility, bioactivity,
improved sealing, and hydrophilicity.6 Other names for the same type or material are calcium sil-
icate cement, bioactive bioceramics, or hydraulic silicates; all such materials are based on the
ceramic of tricalcium silicate cement, which is the term used herein. The indications for these cements
have broadened with new endodontic sealer products for use with gutta-percha and are the subject
Copyright ª 2022
of this review.
American Dental
Association. All rights The International Organization for Standardization (ISO) 6876:20127 and American National
reserved. Standards Institute (ANSI) and American Dental Association (ADA) ANSI/ADA 57:20008

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standards for endodontic sealing materials contain criteria for flow, working time, setting time, film
thickness, solubility, radiopacity, and dimensional stability (ANSI/ADA 57 only). ISO 740510 is a
standard for biocompatibility of dental materials. The requirements of these standards are provided
in Table 1 with the corresponding Grossman criteria.1 Table 1 includes 2 new criteriadbioactivity
and puritydwhich we will discuss.
Previous reviews of tricalcium silicate cement sealers12-15 have not compared the properties that
Grossman described with those that the ANSI/ADA and ISO standards prescribed. These sealers
have become popular in their clinical use.4,6,16,17 However, they are more expensive than tradi-
tional sealers, and the question remains whether they satisfy the Grossman, ISO, and ANSI/ADA
criteria for ideal properties. In this narrative review, we compared the literature on tricalcium sil-
icate cement sealers’ ability to meet the Grossman,1 ISO 6876,7 ISO 7405,10 and ANSI/ADA
57:20008 requirements. Comments are included on the clinical suitability of the tricalcium silicate
cement sealers versus other chemical matrices.

METHODS
Eligibility criteria
Studies that included physical properties of all tricalcium silicate cement sealer types were included.
Both in vivo and in vitro studies were considered. Articles that did not meet these criteria were excluded.

Search strategy
The following 3 databases were searched electronically: Cochrane, PubMed (MEDLINE), and
Embase. The following Medical Subject Heading terms were searched: sealers, endodontic sealers,
endodontic seal, root canal seal, bioactive sealer, calcium silicate, tricalcium silicate, bioceramic sealer,
bioceramic root canal, dicalcium silicate, tri/dicalcium silicate sealer, and MTA or mineral trioxide aggregate
sealer. Textbooks and gray literature were also examined for the physical properties of tricalcium
silicateebased sealers. Publications were searched without a year limit through August 2021. Two
authors (A.A., C.P.) also hand searched textbooks and references. From the literature, this narrative
review was written following the considerations of Gasparyan and colleagues.18
Of 220 published articles, 94 were examined (Figure). Table 1 lists the physical properties ac-
cording to the criteria. Eleven sealers that contained tricalcium silicateebased sealers, from 8
manufacturers, were identified in the literature search and are listed in Table 2. The formats of the
product allow convenience of single paste products versus the customization of the viscosity and
faster setting for powder and liquid products. The MTA-Fillapex sealer (Angelus Dental) was
included, although it is based on resin because it also contains MTA (15%), tricalcium silicate,
dicalcium silicate, calcium oxide, and tricalcium aluminate (Table 2).
Four distributors market the Innovative Bioceramix sealer formulas under several trade names:
iRoot SP (Innovative Bioceramix), Brasseler (Endosequence BC Sealer), EdgeEndo (EdgeEndo
Sealer), and FKG Dentaire (TotalFill BC Sealer). When results are reported for the Brasseler or
TotalFill sealers, it can be concluded that the results apply to all brands of these products. ProRoot
ES endodontic sealer (Dentsply Sirona) was not included because it was removed from the market
after its introduction in May 2016. It was replaced, as of September 2021, with AH Plus Bioceramic
sealer, made by Maruchi, and may be identical to Maruchi’s EndoSeal MTA.
In the following narrative, the Innovative Bioceramix and Maruchi sealers, Bio-C (Angelus
Dental), and other premixed pastes sealer products are referred to as the single paste sealers and
MTA-Fillapex is resinetricalcium silicate cement sealer. The tricalcium silicate single paste sealers
were grouped. The available data on the sealers were compared with each criterion (Table 3) and
ABBREVIATION KEY
will be discussed.
ADA: American Dental
Association.
Literature review ANSI: American National
Placement (Flow, Film Thickness, Working Time, Initial Setting Time, and Method) Standards Institute.
Ease of placement is a vague Grossman criterion, implying a paste that allows extensive filling of the ISO: International
fine root canal anatomy.1 The ISO 68767 standard’s requirements on properties of flow and film Organization for
Standardization.
thickness have a bearing on ease of placement. The flow requirement therein is that 0.05 mL of
MTA: Mineral trioxide
paste should form a circular patty larger than 17 mms in diameter under a 120-g weight. No upper aggregate.
limit exists for in this standard excessive flow is deemed to be undesirable because of possible ppm: Parts per million.

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 Table 1. Endodontic sealer criteria.

ISO* 6876:2012,7 ANSI/ADA† 57:2000,8

COMBINED CRITERIA GROSSMAN REQUIREMENT1 ISO 9917-1,9 AND ISO 740510 REQUIREMENTS
Placement Ease of placement Flow: > 17 mm per test method
Film thickness: < 50 mm; may be a surrogate for sealing
and ease of placement
Working time: to be stated
Initial setting time: to be stated

Shrinkage/Expansion Dimensionally stable < 1% shrinkage and < 0.1% expansion

Antimicrobial Bacteriostatic or antimicrobial Not specified

Discoloration Stain resistant Not specified

Resistance

Sterilizability Sterilizable Not specified

Sealing Hermetic seal when set and adhesion Not specified

with canal walls

Solubility Impervious to moisture, insoluble to < 3% weight per test method

tissue fluids

Radiopacity Not specified > 3 mm aluminum for 1-mmethick sample

Biocompatibility Not irritating to periapical tissue Refer to ISO 740510 for battery of tests

Retreatability Solvent soluble Not specified

Moisture Impervious to moisture Not specified

Adhesion Adequate adhesion to canal walls Not specified

Bioactivity Not specified Refer to ISO 2331711 for precipitation of hydroxyapatite

Purity Not specified < 2 parts per million arsenic, < 100 parts per million lead leachable

* ISO: International Organization for Standardization. † ANSI/ADA: American National Standards Institute/American Dental
Association.

Records identified through Additional records identified

Identification

database searching through other sources

(n = 218) (n = 2)

Records after duplicates removed

(n = 220)
Screening

Records screened Records excluded

(n = 97) (n = 123)

Full-text articles assessed

Full-text articles excluded
Eligibility

for eligibility
(n = 1)
(n = 95)

Studies included in
qualitative synthesis
(n = 94)
Included

Studies included in quantitative

synthesis (meta-analysis)
(n = 0)

Figure. Preferred Reporting Items for Systematic Reviews and Meta-Analyses19 flow diagram that included searches of
databases and registers on tricalcium silicate sealers.

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Table 2. Composition of tricalcium silicate cement sealers

SEALER NAME MANUFACTURER FORMAT MANUFACTURER’S SUPPLIED COMPOSITION

AH Plus Bioceramic, Dentsply Sirona and Maruchi Single paste Tricalcium silicate, calcium aluminates, calcium aluminoferrite, calcium
Endoseal MTA sulfates, radiopacifier, thickening agents, lithium carbonate, and
thickening agents

Bio-C Angelus Dental Single paste Tricalcium silicate 65%, calcium aluminate, calcium oxide, calcium ions,
hydroxyl ions, and zirconia

BioRoot RCS Septodont Powder and liquid Powder: tricalcium silicate

Liquid: aqueous calcium chloride solution and excipients

CeraSeal Meta Biomed Single paste Tri-/dicalcium silicate, zirconia, rheology modifier, and nonaqueous
liquid

HiFlow, Endosequence BC Innovative Bioceramix Single paste Tricalcium silicate, dicalcium silicate, zirconia, calcium hydroxide, and
Sealer, or TotalFill fillers

Endosequence BC TotalFill, Innovative Bioceramix Single paste Tricalcium silicates, calcium phosphate monobasic, calcium hydroxide,
iRoot, or EdgeEndo zirconia, fillers, and thickening agents

MTA*-Fillapex Angelus Dental Dual resin paste Salicylate resin, bismuth trioxide, fumed silica; mixed with fumed silica,
titanium dioxide, MTA (40%, tricalcium silicate, dicalcium silicate,
calcium oxide, and tricalcium aluminate), and base resin (pentaerythritol,
rosinate, and p-toluene sulfonamide)

NeoSEALER Flo Avalon Biomed Single paste tricalcium silicate, calcium aluminate, tantalum oxide, and nonaqueous
liquid

NeoMTA Plus and NeoMTA 2 Avalon Biomed Powder and liquid Powder: tri-/dicalcium silicate and tantalum oxide
Liquid: aqueous solutions of proprietary water-soluble polymers

Sealer Plus BC MK Life Single Paste Tricalcium silicate, zirconia, and calcium hydroxide

Tech BioSealer Endo Isasan Powder and liquid Powder: white Portland cement, bismuth oxide, [calcium sulfate]
anhydride, and sodium fluoride (perhaps montmorillonite)
Liquid: 4% articaine and 1/100.000 epinephrine solution3

* MTA: Mineral trioxide aggregate.

extrusion beyond the apical foramen. The single paste sealers and resinetricalcium silicate cement
sealer satisfied the flow requirement20-23 and Sealer Plus BC (MK Life) adhered to the standard’s
requirement.16 The flows of 2 Korean single paste sealers were also acceptable but were noted to
have longer setting times than those reported from the respective manufacturers.24 The BioRoot
RCS (Septodont) powder and liquid system had lower flow than required in ISO 6876,25 although
this might indicate too much powder was used in the testing.
A root canal sealer should have a film thickness less than 50 mm under a 150-N force.7 BioRoot
RCS had a higher film thickness than what ISO 6876 recommended,25 although it is possible too
much powder was used for this test as well.
Few working times have been reported, but the setting times for these materials are a few hours at
a minimum. Setting times vary widely, with some reports of nonsetting after 5 hours or 1 week26 or 1
month,27 or in dry conditions.28 Two single pastes set in approximately 200 through 600 mi-
nutes,20,21 and another reported setting only after 48 hours,23 which is significantly longer than the
setting time reported by the manufacturers. Animal studies confirmed setting of the single pastes
after 1 week.29 The single paste tricalcium silicate cement sealers require water to initiate the setting
reaction,6 which influenced the in vitro test results for the single paste tricalcium silicate end-
odontic sealers.

Shrinkage and Expansion

ANSI/ADA 57:20008 requires endodontic sealers to have linear shrinkage of less than 1% and to
expand less than 0.1% in length. Micro-computed tomography tests report that the volumetric
contraction of 2 single paste tricalcium silicate cement sealers (TotalFill BC, Bio-C Sealer) was 1%
through 2%.20 Investigators from another study reported higher values of more than 1% (TotalFill
BC).21,30 Two other single paste sealers (CeraSeal [MetaBiomed], EndoSeal) had expansion of less
than 0.5%.24 The resin-based tricalcium silicate and a single paste sealer (MTA-Fillapex, Endo-
sequence BC) were reported to be dimensionally stable.22 The same single paste sealer and 2 others
(TotalFill BC, Sealer Plus BC, Bio-C Sealer) were reported to have a volumetric contraction

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 beyond the minimum level required in ANSI/ADA 57, which was attributed to their solubility.31
Other authors have suggested that solubility and dimensional stability should be evaluated with the
same experiment.30 Test methods may need revision to get consistent results.

Antimicrobial
Root canal treatment is required because a microbial invasion has formed a biofilm that cannot be
eradicated via the body’s immune system. The tricalcium silicateebased sealers are antimicrobial to
some planktonic bacteria and yeast32-36 owing to their high pH.
The resin-based sealer was reported to reduce bacteria in mature biofilms,37 more than AH Plus
Bioceramic and similar to Sealapex (Kerr Endodontics) sealers. Sealapex and MTA-Fillapex both
contain salicylate resins and release calcium hydroxide, creating a pH of approximately 10. A single
paste sealer was reported to be antimicrobial against Enterococcus faecalis when placed after sodium
hypochlorite irrigation,38 in a biofilm,39 and in dentinal tubules.40 A single paste sealer was superior
to a powder and liquid sealer and resinetricalcium silicate cement sealer.41

Discoloration Resistance
Gradual discoloration of the original tricalcium silicateecontaining materials has been traced to
presence of bismuth oxide in the formulas, for radiopacity.42-47 Bismuth oxide is a multivalent ion
that changes color from yellow to brown or gray after exposure to certain chemicals and light.
MTA-Fillapex, containing bismuth oxide, discolored in laboratory investigations.48-50 Tech Bio-
sealer Endo (Isasan) is a cement powder and liquid product that also contains bismuth oxide for
radiopacity. Discoloration is a long-standing issue in endodontics51 that has been reported for other,
nonetricalcium silicate endodontic sealers.52 The following discoloration causes have been iden-
tifed53-57: metal oxides, such as iron-containing phases58; hemoglobin denatured via the alkaline
sealers59,60; bismuth oxidation via irrigants, such as sodium hypochlorite61 smear layeresealer in-
teractions56; and low dentin thickness and large tubules size, which darkened when obturated,
perhaps owing to prior mechanisms.57

Sterilizability
Gutta-percha and paper points are available as sterile, or sterilizable, but sealers are not. Good
clinical practices emphasize the handling and placement of endodontic sealers with disposable tips
or sterilized instruments, with a rubber dam, in conjunction with numerous irrigants to reduce
bacteria before obturation. ISO 6876:2012 does not require sterility for endodontic sealer materials.7

Sealing
Endodontic obturation should achieve a fluid-tight seal, impervious to bacteria. Many methods
have been used to compare the sealing of materials, including bacterial migration, dye infiltration,
fluid filtration, adaptation to the canal walls, tubule penetration, micro-computed tomography, and
push-out bond strength testing. For instance, adaptation of a single paste sealer was evaluated using
digital periapical radiographs. The adaptation of a single paste tricalcium silicate cement sealer and
its penetration into the dentinal tubules was superior to an epoxy resinebased sealer.62 Results of
scanning electron microscopy showed that a single paste sealer had a fluid-tight seal.63 A tricalcium
silicate cement sealer was reported to fill lateral canals more effectively with continuous wave
condensation than the single-cone technique.64 Under confocal laser scanning microscopy, the
tricalcium silicate cement sealer penetrated dentinal tubules from 7% through 82% in the apical
and coronal portions.65 No difference in microleakage was reported between a tricalcium silicate
paste and epoxy resin sealer using the fluid filtration method.66 In a dye leakage study, a single paste
tricalcium silicate cement sealer had less leakage than silicone-based or resin-based sealers, although
none produced a fluid-impervious seal of the apical foramen.67,68 A “high flow” single paste tri-
calcium silicate cement sealer penetrated tubules with continuous wave condensation, examined via
confocal laser scanning microscopy and scanning electron microscopy.69

Solubility
The ISO 6876 requirement for solubility states that it should not exceed 3% weight when set, disk-
shaped samples are exposed to water for 24 hours at 37  C. The single paste tricalcium silicate
cement sealers are reported to have high solubility in this test,14,70 and 13.5% mass loss in 30 days.21
The single paste sealers met the requirement in other studies.22,26,31

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 MTA-Fillapex was reported to have high solubility and did not meet ISO 6876 requirement in
studies,30,37,71 nor did a powder and liquid sealer.16,17,72,73 Investigators from 1 study reported the
resinetricalcium silicate cement sealer met the solubility requirement.73
During setting, the single-paste tricalcium silicateebased sealers must absorb water to set. This is unlike
the 2-paste or 2-powder sealer compositions, which start to set when mixed. The solubility test method
has not been updated for tricalcium silicateebased sealers that require exogenous water for setting.

Radiopacity
The ISO 6876 standard requires the radiopacity of a root canal sealer to be more than 3 mm of
equivalent aluminum (3 times more radiopaque than dentin), so that the set sealer can be visualized
easily in a radiograph.7 The radiopacity of all of the tested tricalcium silicate sealers exceeded the
minimum radiopacity.14,20,21,23,24,26 The radiopacity of tricalcium silicate cement sealers varies from 5
through 8 mm of aluminum, similar to what was reported for other types of sealers, except for AH Plus
Bioceramic sealer, which has a higher aluminum equivalent, in the range of 9 through 14 mm.20,74

Biocompatibility
Two paste sealers from Brazil (Bio-C Sealer, Sealer Plus BC) and a US-made powder and
liquid sealer (NeoMTA; Avalon Biomed) were biocompatible when implanted subcutaneously
in rats.75,76 The biocompatibility of 2 single paste sealers (CeraSeal, EndoSeal) was acceptable
using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide assay.24 Another single
paste sealer (Endosequence BC) was not cytotoxic after setting.77 A powder and liquid sealer
(NeoMTA) had good biocompatibility in an in vivo canine model when the material was
used as a sealer and obturation of the entire canal space.78 Using human periodontal liga-
ment stem cells, a powder and liquid sealer (BioRoot BC Sealer) was more biocompatible
than a paste sealer (Endoseal MTA).79 These 2 sealers contain tricalcium silicate, but differ
in other aspects of composition; EndoSeal MTA contains an organic carrier and more free
silica.
MTA-Fillapex is the only sealer in Table 2 that is primarily resin, yet this sealer has been
considered MTA-based, although containing less than 15% MTA. A consequence of the resin is its
cytotoxicity at a concentration of 50 mg/mL for 2 weeks77,80,81 and was higher cytotoxicity than
single paste tricalcium silicate cement sealers.20,82 Similar findings were reported when implanted
and compared with 3 single brands of paste sealers.83-85 Tricalcium silicateebased sealers are at
minimum equivalent in biocompatibility to traditional endodontic sealers, except for those that
include resin as a sealer component.86

Retreatability
Retreatment may be appropriate if poor obturation technique is used or other circumstances occur.
After setting, tricalcium silicateebased sealers are insoluble in organic solvents commonly used in
endodontics, such as ethanol or chloroform.87,88 A single paste sealer had residue remaining after
chloroform treatment,89 but ultrasonic instrumentation reduced the remnant sealer considerably.90
Tricalcium silicateebased materials are soluble in acids; concentrated acids used for prolonged
treatment can demineralize dentin and denature the demineralized dentin collagen matrix.91
Chemical and mechanical methods have been used together for retreatment. Ten percent formic
acid with mechanical instrumentation was reported to be effective method for removing set tri-
calcium silicateebased sealers.92 Removal of these sealers with rotary instrumentation or a manual
technique was no worse for resin-based sealers.93,94 Rotary retreatment files could not completely
remove any of the sealers (resin-based, tricalcium silicateebased),94 even with sonic activation.95
However, other instruments for retreatment have not been fully investigated, including ultrasonic
and “self-adjusting” files. The potential benefits of these armamentarium remain elusive at this time.
Tricalcium silicateebased sealers penetrate into the dentinal tubules,69,96-99 as some sealers also
penetrate into the dentinal walls. However, ceramic cements in the tubules, rather than polymers,
potentially complicate removal and retreatment. However, the necessity for the entire removal of
tricalcium silicateebased sealer from the dentinal tubules has not been established as a criterion for
successful retreatment.69

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Table 3. Conformation of tricalcium silicateebased root canal sealer to Grossman criteria1 or International Organization for Standardization or American
National Standards Institute/American Dental Association8 requirements.

PLACEMENT DIMENSIONAL DISCOLORATION

SEALER NAME (MANUFACTURER) PROPERTIES STABILITY ANTIMICROBIAL RESISTANCE STERILIZABLE SEALING
AH Plus Bioceramic, Endoseal MTA Yes* Unknown Unknown Unknown Unknown Unknown
(Dentsply Sirona and Maruchi)

Bio-C (Angelus Dental) Yes Unknown Unknown Unknown Unknown Unknown

BioRoot RCS (Septodont) Yes Yes Yes Unknown Unknown Unknown

CeraSeal (Meta Biomed) Yes Unknown Unknown Unknown Unknown Unknown

HiFlow, Endosequence BC, or TotalFill Yes Yes Yes Unknown Unknown Yes
(Innovative Bioceramix)

Endosequence BC, TotalFill, iRoot, or Yes Yes Yes No Unknown Yes

EdgeEndo (Innovative Bioceramix)

MTA-Fillapex (Angelus Dental) Yes Yes Yes No Unknown Unknown

NeoSEALER Flo (Avalon Biomed) Unknown Unknown Unknown Unknown Unknown Unknown

NeoMTA 2 (Avalon Biomed) Unknown Unknown Unknown Unknown Unknown Unknown

Sealer Plus BC (MK Life) Yes Unknown Unknown Unknown Unknown Unknown

Tech BioSealer Endo (Isasan) Unknown Unknown Unknown Unknown Unknown Unknown

* “Yes” indicates that product is documented as having this characteristic. † “No” indicates that product is documented as deficient in characteristic.

Moisture, Adhesion, and Bioactivity

Table 2 shows that these materials are based on tricalcium silicate cement, which requires water to
set (hydraulic setting). Therefore, these types of sealers are inherently hydrophilic, to meet 1 of the
Grossman criteria.1 Results of the microshear bond strength test showed some adhesion of the
tricalcium silicate cement sealers to gutta-percha disks,100 although less than an epoxy resinebased
sealer. The adhesion of the tricalcium silicate cement sealers and their ability to attach to dentinal
walls may be augmented by means of bioactivity; that is, the precipitation of hydroxyapatite crystals,
and the sealer fills in voids and creates frictional (mechanical) adhesion at the dentinal wall.
Bioactivity, defined in ISO 23317 as the ability to form a layer of carbonated apatite on the
surface of a material after immersion in synthetic body fluids, is a desirable characteristic for end-
odontic sealers101 that Grossman did not anticipate. Apatite crystallite formation on the surface of
the sealer within the root canal can help fill the canal space formerly occupied with the dental pulp.
These crystals may obstruct bacterial migration that can cause subsequent infection.
Calcium hydroxide has long been recognized as bioactive material in vital pulp therapy and other
endodontic procedures,102 prompting its use in endodontic sealers, a benefit that exists for trical-
cium silicate cementebased sealers.103,104
Tricalcium silicateebased sealers release calcium hydroxide as a reaction product on hydration,
creating a pH higher than 10 within a hard matrix of hydrated tricalcium silicate that persists for at least
3 weeks.20 The high pH and the phosphate ions in tissue fluids precipitate carbonated apatite on the
surface of the set sealers105,106 to induce osteogenic effects.107 Several tricalcium silicate cement sealers
have been shown to biomineralize76,108 or show osteoblastic differentiation,109 fibroblast proliferation in
an in vitro model,110 induced angiogenic osteogenic growth factors,103 and periodontal ligament pro-
liferation.111 However, the latter study and another112 had cytotoxic results for MTA-Fillapex.
Although MTA-Fillapex contains approximately 15% MTA, its composition is mostly resin.12 Many
researchers believe that this sealer should not be evaluated in the bioactivity category.2 MTA-Fillapex
sealers had minimal and delayed apatite precipitation compared with 2 single paste sealers.113

Purity
Water-setting dental cement is subject to ISO 9917-1 requirements,9 which include freedom from
soluble arsenic or lead (< 2 parts per million [ppm] and < 100 ppm, respectively). The first tri-
calcium silicate dental materials were reported to contain 1 through 35 ppm of arsenic,114,115
although other researchers reported only parts per billion.114,116 High lead has not been found in
any such product.115 No studies have reported impurities in the tricalcium silicate cement sealers.
The probability of impurities is low for these sealers, given the attention given to early products.

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Table 3 (Continued)

SOLUBILITY RADIOPACITY BIOCOMPATIBLE RETREATABLE MOISTURE ADHESION BIOACTIVITY PURITY

†
No Unknown Yes No Unknown No Unknown Unknown

No Yes Unknown Unknown Unknown Unknown Unknown Unknown

No Yes Yes Unknown Unknown Yes Unknown Unknown

Unknown Unknown Yes Unknown Unknown Yes Unknown Unknown

No Yes Yes No Unknown Yes Unknown Unknown

Unknown Yes Yes No No Yes Unknown Unknown

No Yes No No No No No Unknown

Unknown Unknown Yes Unknown Unknown Unknown Yes Unknown

Unknown Unknown Yes Unknown Unknown Unknown Yes Unknown

No Yes Unknown Unknown Yes No Unknown Unknown

Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

DISCUSSION
To our knowledge, this is the first review that compares all of the properties of endodontic sealers on
the basis of the combined ideal properties of Grossman,1 ANSI/ADA 57:2000,8 and ISO
6876:20127 requirements for endodontic sealers. Results of the literature search in our review
showed that the physical properties of the first tricalcium silicate cement sealers meet many of the
ideal properties from Table 1, as indicated in Table 3. The competitive and newer materials are not
as well studied, but have a similar composition to the first sealers and to the endodontic repair
materials, originating with ProRoot MTA (Dentsply Sirona ).2,84
These sealers perform well clinically with adequate placement, working time, and setting
times.2,24,27 They are dimensionally stable with either minor expansion or shrinkage.71 Some anti-
microbial characteristics are present, but more research is needed to ascertain whether the antimi-
crobial properties are sufficient to neutralize or destroy biofilms.117 Although they cannot be sterilized,
their sealing ability is similar to that of the tricalcium silicate materials for perforation and filling the
root end. The radiopacity, biocompatibility, and purity are adequate and their moisture compatibility
is better because these sealers require water to set.26 Adhesion, although desired, may not be sub-
stantial with the gutta-percha, but it was reported to be better than epoxy-resin bond to dentinal
walls.99,118 Most researchers examined this criteria using push-out bond strength testing.119-123
Weaknesses of these sealers are the confusing and high values of solubility. However, the solu-
bility may be confused with calcium hydroxide release to make the sealer bioactive. The calcium
hydroxide present on the surface after setting may be dissolved in water, which has led to high
values of solubility that would normally indicate the sealer is dissolving, despite the well-known
impervious nature of set tricalcium silicate cement sealer.4 When tricalcium silicate cements
were tested in Hanks’ Balanced Salt Solution, the solubility was miniscule compared with testing in
water. In synthetic body fluid liquids, the tricalcium silicate cements will rapidly cause precipitation
of hydroxyapatite on their surface. This layer slows the release of calcium hydroxide from the
cement compared with immersion in water. The consequence is lower solubility. Therefore, the
solubility values that exceed the ISO 68767 requirement inaccurately reflect the clinical situation
when such cement sealers would be stable and nonresorbable.
Furthermore, the formation of surface hydroxyapatite by means of bioactivity added the weight of
the precipitated crystals and minimized the elution and weight loss of surficial calcium hydroxide.
The solubility method of ISO 68762 is suitable for most sealer types, but not for the bioactive
cements that release of calcium hydroxide,30 necessary for bioactivity.14
Other weaknesses of the tricalcium silicate cement sealers are the potential for discoloration and
inability to sterilize the material, but the latter is a universal issue for dental materials that must be

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 set interorally. Discoloration of endodontic materials is well known51; however, a particular
discoloration phenomenon has been identified for bismuth oxide in tricalcium silicate cements.46
Discoloration with these sealers is not well documented clinically in terms of frequency and in-
tensity induced by means of these sealers. Therefore, standardized in vitro and in vivo studies with
long periods of follow-up are needed.124
Lastly, the retreatability of the canals with these sealers requires instruments, as solvents are not
suitable. Certainly, the use of common endodontic solvents do not soften the calcium silicate
sealers, but in combination with a gutta-percha cone, there is a pathway that allows removal of the
root canal filling. As long as at least 1 gutta-percha cone is used, removal for retreatment is possible.
Furthermore, the endodontic tricalcium silicate cements contain more inert, noncementitious
radiopaque powder, which creates a weaker layer that is more easily removed than the root-end
filling materials.
The unique capability of these sealers for bioactivity and biomineralization supports their use for
healing apical periodontitis.125 A highly favorable clinical and radiographic healing outcome of
91% was reported at 1-year recall visit when a single paste sealer was used with a single-cone
obturation technique and evaluated in 307 teeth.126 Extrusion of tricalcium silicate cement
sealers did not adversely affect the outcome,126 as it might have with traditional sealers127;
nevertheless, intentional overfilling should be avoided.128,129

CONCLUSIONS
With the limitations of our review, tricalcium silicateebased sealers meet many of the ideal end-
odontic sealer criteria of Grossman (that is, ease of placement, antimicrobial, sealing, radiopacity,
biocompatibility, and adhesion) with the added benefit of bioactivity. However, the published data
on solubility do not meet the ISO 6876 standard criteria. Discoloration may be linked to these
sealers, particularly those containing bismuth oxide.
The long-term clinical performance of these tricalcium silicate cement sealers has not been
definitively reported, although inferiority has not been reported. The properties of tricalcium silicate
cement sealers approximate those of an ideal root canal sealer, but new research on the burgeoning
array of such products is warranted. If the clinician has no intention of retreating the case and
surgery would be the next option, using these sealers may be of benefit. The tricalcium silicate
cement sealers are more expensive than the traditional sealers. The question remains whether their
bioactivity justifies the increased expense compared with traditional sealers. n

Dr. Aminoshariae is the director of predoctoral endodontics, School of Dr. Kulild is a professor emeritus, UMKC, Department of Endodontics,
Dental Medicine, Case Western Reserve University, 2123 Abington Rd, A Kansas City MO.
280, Cleveland, OH, email Axa53@case.edu. Address correspondence to Disclosure. None of the authors reported any disclosures.
Dr. Aminoshariae.
Dr. Primus is a consultant for NuSmile NioMTA, and is an adjunct
associate professor, College of Dentistry, Augusta University, Augusta, GA.

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