Oral Health Group
Feature

Bonded Obturation: Time for New Shoes

May 1, 2007
by Richard Mounce, DDS


In the July, 2004 issue of Oral Health in an article called “Bonded Obturation, A Quantum Leap Forward for Endodontics” Dr. Gary Glassman and I stated, “The surgical operating microscope and the advent of rotary nickel titanium instrumentation have both provided a quantum leap forward towards a higher standard of endodontics. Adhesion has done much the same for restorative dentistry. Blending the best of adhesion into endodontic obturation has now become reality. In the authors’ opinion, adhesion in canal obturation represents another quantum leap forward for the specialty.” We went on to conclude in the same article that “…over the next decade, as studies in all probability will continue to validate this material, it is very possible that gutta percha will become obsolete until another material can be found which will give greater clinical benefit with less patient risk such as RealSeal. In the authors’ opinion, this material truly is a quantum leap forward in the modern era of endodontics and worthy of consideration for use as an obturating material in place of gutta percha.”

Three years on, has our opinion been validated? I believe it has. At present, there have been at least 98 references to Resilon and RealSeal (Resilon Research LLC, (Madison, CT and SybronEndo, Orange, CA, USA respectively) in PubMed and ResilonResearch. com in the form of abstracts, research papers, trade publication articles, etc. In summary, the significant majority of the articles published on this material have been positive or shown that the material is no worse than gutta percha with the detailed exceptions. A comprehensive list of references derived from Pubmed and ResilonResearch.com is given in the bibliography 1-98. The reader is also directed to http://scholar. google.com/ for additional references. It is noteworthy that seven of the nine papers that are negative about the material have two authors in common.17,62,66,90-92,98 Never in the memory of the author has a single endodontic product generated so much interest, controversy or debate. This paper was written to update the reader in general terms on the existing research, discuss its clinical usage and provide a comparison to gutta percha that frames its significance.

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Incontrovertible facts about gutta percha:

1) Gutta percha has no inherent ability to seal canals, except perhaps by a physical one with the flow into lateral canals via warm vertical techniques.

2) Gutta percha does not bond to canal walls.

3) Gutta percha does not bond to any sealers.

4) For all intents and purposes, gutta percha is a filler that has no other significant function. It has been chosen because of its lack of toxicity, ability to be thermosoftened and compacted, ability to be retreated and its lack of an alternative (up to the present time) more than any other single set of factors.

5) Gutta percha is almost wholly dependent on a coronal seal to prevent the apical migration of bacteria if it’s challenged by coronal leakage. The endodontic literature is absolutely clear that excellent coronal seal is correlated with clinical success irrespective of the presence of gutta percha.99-104

6) Only resin-based sealers have the potential to bond to canal walls when the smear layer has been cleared with a liquid EDTA solution.

7) Gutta percha shrinks upon cooling approximately 5-7%.

8) Gutta percha has changed very little since it was introduced into dentistry at the beginning of this century.

The clinical ramifications of these facts are myriad. One very significant clinical issue occurs daily in endodontic specialist practices across the world. It is a common scenario for the endodontist to treat the tooth under a rubber dam and often a surgical operating microscope (SOM) and then place a cotton pellet and temporary filling because the referring doctor wishes to seal the access permanently. Far more often than it should (which is never), this results in a cotton pellet that is left in the access by accident during the second access procedure by the general dentist during build up placement. Coronal microleakage and subsequent clinical failure are predictable with a cotton pellet left in this manner.

The mechanism of failure is clear. Many times, the build up is placed without either a rubber dam or SOM visualization risking salivary contamination and subsequent iatrogenic events. Without a rubber dam or SOM visualization, the clinician lacks ideal visual control and operative command over the access cavity. Having a clinician who did not do the root canal can also easily lead to perforation of a root wall in post space preparation. In addition, even with loupes and a light source, there can be challenges visualizing all ramifications of the cavity reparation especially in a tooth with limited physical access.

Coronal microleakage during and after build up placement (with and without posts) is a real risk and represents the “weak link” in the present customary set of practices. Empirically, it is my observation that most general dentists want to do their own build ups. When queried as to why, it is often stated that they need the production in their practices or that they feel that they can do a better job in the build up placement. Which is the more technically challenging procedure, the root canal or the build up? And if the patient were the referring doctor’s mother, would they rather have the build up and post placed under a rubber dam and SOM or without? Which of these scenarios is more consistent with empirical experience and the literature with an eye toward providing clinical success?

All of the above alone underscore the vital importance of utilizing all means of reducing and eliminating coronal microleakage, one of these being the use of a bonded obturation material. A bonded obturation can and does help achieve these objectives.

TECHNICAL AND HISTORICAL BACKGROUND

In 2003, Resilon Research introduced Resilon obturating points and Epiphany sealer into the commercial marketplace. SybronEndo licensed the material as RealSeal. I utilize the material as RealSeal and it will be referenced as such. The material is used clinically exactly like gutta percha in that it can be applied with warm or cold obturation techniques. The points look, feel; handle clinically, almost identically to gutta percha. The material can be retreated with gutta percha solvents. Chemically, the material is “…a thermoplastic synthetic resin material based on the polymers of polyester and contains a difunctional methacrylate resin, bioactive glass and radio opaque fillers. RealSeal sealer contains UDMA, PEGDMA, EBPADMA and BisGMA resins, silane treated barium borosilicate glasses, barium sulfate, silica, calcium hydroxide, bismuth oxychloride with amines, peroxide, photo initiator, stabilizers and pigment. RealSeal Primer is an acidic monomer solution in water. RealSeal is non-toxic, FDA approved and non mutagenic. With its radio opaque fillers, RealSeal is a highly radio opaque material. The sealer is resorbable.” (Oral Health, July 2004, Glassman, Mounce)

The reduction of coronal microleakage occurs as a function of RealSeal’s ability to be bonded to the canal wall through the creation of a hybrid layer. In essence, the core material is bonded to the chemically similar sealer and self-etching primer. Said differently, once the smear layer is cleared with a liquid EDTA solution like SmearClear (SybronEndo, Orange, CA, USA) the open tubules and dentin wall are covered with the self-etching primer. A hybrid layer is created on top of this with the placement of the sealer. This bonding diminishes in a statistically significant manner the amount of bacteria that might otherwise be able to migrate in a coronal to apical direction. The advance that this represents for endodontics and dentistry is hard to overstate given the issues of gutta percha detailed above.

From January 2004 to the present, I have exclusively used RealSeal clinically. I cannot envision
ever returning to gutta percha. Clinically, using RealSeal is simple. As mentioned, the material can be compacted with cold lateral condensation, a single cone technique, warm compaction and is available in the form of SimpliFil R (Discus Dental, Culver City, CA, USA), Resinate (Obtura Spartan, Fenton, MO, USA), Enfuse (Hu-Friedy, (Chicago, IL, USA) as well as RealSeal. I employ the material with the SystemB obturation technique observed through the SOM. The source of both the heat for the downpack and backfill is the Elements Obturation Unit (SybronEndo, Orange, CA, USA). The cartridges used in the backfill are single use, economical, disposable and prevent cross contamination. This method has proven reliable, reproducible, and economical and can be easily mastered with practice, especially if practiced initially in extracted teeth. For a comprehensive discussion of SystemB obturation technique, the reader is directed to the above referenced Mounce-Glassman paper in Oral Health from July 2004.

THE DISSENT: THE COMFORTABLE OLD SHOE

Recently, in the article “…Seal after Obturation Techniques…” Brackett, et al JOE. Dec 2006, vol 31, #12, 1188-1190 stated as the final sentence of their article that “…lowest leakage values were obtained in the AH Plus/gutta percha control group. This remains the gold standard against which all new sealers and bondable root filling materials must be measured.” How can a material with known weaknesses like gutta percha be a “gold standard?”

Reasons for not adapting bonded obturation material can be summarized in two words, apathy and inertia. In a sentence, why change when we know gutta percha works, but only sort of?

As mentioned, seven of nine negative papers have two common coauthors. It is interesting to note that virtually everything in these papers is unfavorable to RealSeal. It would take a significant review to discuss these seven papers. However, suffice it say that Dr. Karl Leinfelder Adjunct Professor, University of North Carolina, reviewed five of the seven and stated that they “have bypassed standard scientific practices and their results are therefore called into question.”1

Typical of some of these papers is the fact that RealSeal is challenged with chemicals and scenarios that are not biologically relevant. For example, to quote Dr. Leinfedler speaking about the study referenced in the bibliography as #90: “In this study, highly caustic sodium ethoxide (20%) was used to demonstrate that the plasticizer (polycaprolactone) in Resilon is degradable… (sodium ethoxide) is typically used as deplasticizer for polycaprolactone agents. The selection of this material to test the solubility or biodegradation of Resilon components is not only clinically insignificant but specifically demonstrates a known mode of failure for a single component of Resilon and not the Resilon material itself. It has been documented that polycaprolactone is biodegradable in vivo and that is also highly biocompatible. Due to the potential for biodegradation, polycaprolactone is compounded with bioactive glass during Resilon synthesis for the purpose of generating mineralization should degradation occur.” This speaks for itself.

Some studies lack controls or are purely observational and yet the authors at times draw absolute conclusions.

In addition, it is challenging to understand how gutta percha can seal better in any of the studies that claim so. Gutta percha cannot bond to sealer or canal walls. RealSeal can bond to both through a cleared smear layer using of a self-etching primer and sealer. With a chemical bond between the filling material and the sealer, one of the major avenues of leakage has been diminished relative to gutta percha. Empirically, this finding leads me to question the methodology employed to derive a finding where gutta percha now seals better than a product designed specifically for this purpose. In short, this research does not match the clinical experience I have with the material in FT endoodntic practice. After three years of daily use, not a single obturation has shown any degradation upon recall. In fact, in every single case that has had apical surplus of core filling material at the time of obturation, the surplus is still there at the recall evaluation while as expected in some cases some amount of sealer may have resorbed, a desirable finding.

Never before that I am aware of has a material at its introduction received such a public greeting at its launch. Dentsply Tulsa Dental (Tulsa OK, USA) sent a letter in 2004 to numerous opinion leaders around the world and alleged that obturation based on Resilon technology might be degradable, lack the ability to seal, not bond to dentin and have unfavorable solubility characteristics in water.

In addition, it has also been rumored that RealSeal is degradable in canals possibly arising from the article cited above. There is absolutely not a shred of published proof to back this assertion aside from the studies mentioned. An individual making this claim recently sent me a series of radiographs. To preserve confidentiality upon request, I cannot publish those films, but I can say that what was purported to be degradation of the material was a sealer puff that had been eliminated, a desirable event. The core material in the material was unchanged, as expected.

In November 2004, the presidents of Pentron and SybronEndo published a public letter that responded to Dentsply’s. They countered, “we do not agree with Dentsply’s insinuation that the Resilon material “might” or “possibly” could degrade through some method of action they do not disclose. If this were to occur when some of the material was expressed into the peri-radicular tissues, it would be considered a positive property.”

In addition, they went on to say:

“Resilon’s effectiveness is demonstrated in peer-reviewed research. Peer reviewed studies show Resilon to be a responsible choice for endodontics. We do not agree that Dentsply’s product evaluation was “intensive”, as it virtually ignores the peer reviewed, published research on the Resilon material. The “independent” studies alluded to in the letter were not peer reviewed or independently published. A portion of that research — specifically the adhesion study — was done in house without disclosure of the methodologies.

Resilon has excellent leakage studies supporting it. We dispute Dentsply’s leakage report. The report, which Dentsply has not released, used an esoteric protocol that was used in only three of approximately 750 published leakage studies. In contrast, the Resilon Material has been evaluated independently by some of the best researchers in the field.

Dentsply’s water sorption study was simply wrong. The results of their water sorption study with the sealer are specious. No absolute values are stated, only relative ones. Dentsply refers to ADA specification 27 and ISO specification 6876 in their letter. ADA specification 27 does not apply to endodontic materials. Our testing has shown that we clearly meet the specifications of both ADA specification 57 (the appropriate specification for endodontics) and ISO specification 6876.

We stand behind this exciting new technology. Our decision to market this technology was based on reliable, peer reviewed, scientific research. As we are certain our research will stand the test of scrutiny…”

It is interesting that the negative studies that were published after these letters were traded were the ones written with the two co-authors in common and are those with the limitations addressed in a review of five of these papers by Dr. Leinfelder.

At present, Pentron estimates that over 11 million RealSeal points have been sold. If the Dentsply claims were true, would we not have a different set of experiences clinically than we actually now have over the past 3 plus years? In addition, what of the very positive research that has been published in the intervening period, is this not without merit or validity?

Even taking into account these negative papers, the over
whelming majority of the remaining studies are either positive with regard to some measured parameter or show that RealSeal is no worse gutta percha. In other words, the material has the potential to be better.

IN SUMMARY

With the progression and trends in dentistry from alloy to adhesion, less gold to more porcelain, from the naked eye to surgical microscopes, from empiricism to evidence based treatment and the rise of minimally invasive dentistry, it is hard to see a present or future in which gutta percha is the gold standard of anything. Adhering to gutta percha as a holy grail and its use as a sacrament is misplaced loyalty in a place within dentistry that is long since overdue for change. To argue otherwise is to place ones head in the proverbial sand out of apathy or indifference and deny our patients the best material we have available for obturating root canals at this time. Gutta percha is old and tired shoe, its time for a new pair.

Dr. Mounce lectures globally and is widely published. He is in private practice in Endodontics in Vancouver, WA, USA. Amongst other appointments, he is the endodontic consultant for the Belau National Hospital Dental Clinic in the Republic of Palau. Korror, Palau (Micronesia). He can be reached at RichardMounce@ MounceEndo.com.

Dr. Mounce would like to thank Dr. Lele Ambu for the images in Fig. 3 & 5. Dr. Mounce has no commercial interest in any of the products or companies mentioned. Dr. Mounce occasionally receives honourarium when he lectures at the request of SybronEndo.

REFERENCES

1.”A Critical Analysis of Recent Research on Resilon Obturation Material”. Karl Leinfelder, CE Digest, 4th Edition, (a peer reviewed publication of the Academy of Dental Therapeutics and Stomatology).

2.”An In Vitro Comparison of the Intraradicular Dentin Bond Strength of Resilon and Gutta-Percha.” Skidmore, Berzins and Bahcall. Marquette University. JOE, Vol. 32, No. 10, October 2006: pp 963-6.

3.”Assessment of the Sealing Ability of a New Root Canal Obturation Material”. Umut Tunga, PhD, DDS* and Emre Bodrumlu, Phd, DDS. JOE Vol. 32, No. 9, September 2006; pp: 876-878.

4.”An In Vitro Assessment of the Sealing Ability of Resilon/Epiphany Using Fluid Filtration.” Biggs et al. Creighton University. JOE, Vol. 32, No. 8, August 2006: pp 759-61.

5.”A Fluid Filtration Comparison of Gutta-Percha versus Resilon, a New Soft Resin Endodontic Obturation System.” Stratton, Apicella and Mines. U.S. Army, Ft. Bragg Endodontic Residency, Ft. Bragg, North Carolina. JOE, Vol. 32, No. 7, July 2006; pp: 642-645.

6.”A Comparison of Thermal Properties Between Gutta-Percha and a Synthetic Polymer Based Root Canal Filling Material (Resilon).” Miner, Berzins and Bahcall. Marquette University, School of Dentistry, Milwaukee, Wisconsin. JOE, Vol. 32, No. 7, July 2006; pp: 683-686.

7.”A Comparative Study of Physiochemical Properties of AH Plus and Epiphany Root Canal Sealants.” Sousa-Neto et al. Universidade de Ribeirao Preto, Brazil. IEJ, Vol. 39, No. 6, June 2006: pp464-71.

8.”A Comparison of Resilon and Gutta-Percha Dissolving Qualities in Endodontic Solvents.” Kunath et al., U.S. Army Dental Facility, Ft. Bragg, NC and Medical College of Georgia, Augusta, GA. Abstract: #PR17, JOE, Vol. 32(3), March 2006.

9.”A Comparison of Coronal Leakage Using RealSeal Sealer and a Dentin Bonding Agent.” Fulsaas et al., Keesler A.F.B., Biloxi, MS, and Louisiana State University, New Orleans, LA. Abstract: #OR53, JOE, Vol. 32(3), March 2006.

10.”A Comparison of Root Canals Filled with Gutta-Percha and Resilon in a Coronal Leakage Model.” Suhler et al. Wilford Hall U.S.A.F. Medical Center, San Antonio, TX. Abstract: #OR13, JOE, Vol. 32(3), March 2006

11.”Antimicrobial Efficacy of medicated Root Canal Filling Materials.” Belanger et al., JOE, Vol. 32(2), February 2006. J Endod. 2006 Feb;32(2):148-51

12.”Apical Adaptation of Root Fillings Completed Using a Soft Resin Canal Filling System.” Ungor et al., Baskent University, Ankara, Turkey. Abstract: #R42, IEJ, Vol. 38(12), December 2005.

13.”Apical Leakage of a New Obturation Technique,” Abstract #42, 31(3), March 2005. Study by Gambarini, et al. Aust Endod J. 2006 Apr;32(1):31-4.

14.”Antimicrobial Potential of Epiphany RCS System” ABSTRACT: 2005 IADR/AADR/CADR 83 rd General Session & Exhibition Y. Li, W. Zhang, O. Onyago, W. Jia, and S. Gagliardi, Loma Linda University, Ca, Pentron Corporation, Wallingford , CT

15.”An in vitro evaluation of the apical sealing ability of a new resin-based root canal obturation system.” Onay EO, Ungor M, Orucoglu H. J Endod. 2006 Oct;32(10): 976-8.

16.”Apical leakage of Resilon obturation material.” Bodrumlu E, Tunga U. J Contemp Dent Pract. 2006 Sep 1;7(4):45-52.

17.”A comparison of cohesive strength and stiffness of Resilon and gutta-percha.” Williams C, Loushine RJ, Weller RN, Pashley DH, Tay FR. J Endod. 2006 Jun;32(6):553-5.

18.”Adhesive Endodontics: Combining Technologies for Enhanced Success” Dentaltown, Vol. 5, Issue 8, August 2004

19.”Adhesion: on its way to the apex!” Degrange M. J Adhes Dent. 2005 Summer;7(2):91.

20.”Biocompatibility of Activ GP and Resilon Cones on L929 Cells In Vitro.” Zhu et al., University of Connecticut, Farmington, CT. Abstract: #OR57, JOE, Vol. 32(3), March 2006.

21.”Bondability of Resilon to Methacrylate-Based Root Canal Sealer.” Haraishi et al., JOE, Vol. 32(2), February 2006. J Endod. 2006 Feb;32(2):133-7.

22.”Biologic perspectives to support clinical choices in root canal treatment.” J.L. Gutmann. Aust. Endod. J., Vol. 31(1), April, 2005.

23.”Bonding of Self-Etching Primer/Polycaprolacton-Based Root-filling Material to Intaradicular Dentin,” ABSTRACT: 2005 IADR/AADR/CADR 83 rd General Session & Exhibition, F.R. Tay, R.J. Loushine, R.N. Weller, W.F. Kimbrough, D.H. Pashley, Y.E. Mak, C.N.S. Lai, R. Raina, and M.C. Williams, University of Hong Kong, China, Medical College of Georgia, Augusta, USA.

24.”Bondability of Resilon to a Root Canal Sealant” ABSTRACT: 2005 IADR/AADR/CADR 83 rd General Session & Exhibition W. Jia, S. Gagliardi, and S. Jin, Pentron Corporation, Wallingford , CT USA

25.”Bonded Endodontic Obturation: Another Quantum Leap Forward for Endodontics,” Oral Health, July 2004 (available online @ www.oralhealthjournal.com

26.”Coronal Leakage of Teeth Root-Filled With Gutta-Percha or Resilon Root Canal Filling Material”. Etienne Pitout, BChD,* Theunis Gerhardus Oberholzer, BSc, BCbD MSc, PhD* Elaine Blignaut, BSc, MSc, BChD, PhD,* and Julitha Molepo, BSc, BSc(Hons), MSc2*. JOE Vol. 32 No. 9, September 2006: pp 879-881.

27.”Cytotoxicity of a New Root Canal Filling Material on Human Gingival Fibroblasts.” Key, Rahemtulla and Eleazer. University of Alabama at Birmingham. JOE, Vol. 32, No.8, August 2006: pp 756-8.

28.”Comparison of the Intraosseous Biocompatibility of AH Plus, EndoREZ, and Epiphany(r) Root Canal Sealers”. Sousa et al. Universidade Federal de Uberlandia, Campus Umuarama, Brazil. JOE, Vol. 32, No. 7, July 2006; pp: 656-662.

29.”Completeness of Root Canal Obturations: Epiphany Techniques versus Gutta-Percha Techniques.” Eppley Et Al. University of Medicine and Dentistry of New Jersey. JOE, Vol. 32, No. 6, June 2006: pp541-4.

30.”Comparison between Gutta-Percha and Resilon Removal Using Two Different Techniques in Endodontic Retreatment.” Teixeira Et Al. University of North Carolina. JOE, Vol. 32, No. 4 April 2006: pp362-4.

31.”Comparative analysis of microleakage and seal for 2 obturation materials: Resilon/Epiphany and gutta-percha”. Aptekar A, Ginnan K., J Can Dent Assoc. 2006 Apr;72(3):245

32.”Comparison of the sealing of Resilon, ProRoot MTA and Super-EBA as Root End Filling Materials: A Bacterial Leakage Study.” Glickman et al., JOE, Vol. 32(4), April 2006. P: 324-7

33.”Comparison of 5.25% Sodium Hypochlorite, MTAD and 2% Chlorhexidine in the Rapid Disinfection of Polycaprolacton
e-Based Root Canal Filling Material.” Royal et al., University of Iowa, Iowa City, IA. J Endod. 2007 Jan;33(1):42-4.

34.”Clinical Performance of Resilon at 12 Months.” Marcos-Arenal et al., University of North Carolina, Chapel Hill, NC. Abstract: #PR20, JOE, Vol. 32(3), March 2006.

35.”Comparison of the Obturation Density of Resilon Using Cold Lateral Condensation and Varying Continuous Wave of Condensation Techniques.” Southern and Jackson. West Virginia University, Morgantown, WV. Abstract: #OR27., JOE, Vol. 32(3), March 2006.

36.”Comparative Study of Sealing Ability of a New Resin-Based Root Canal Sealer.” Kokorikos et al., Aristotle University of Thessaloniki, Thessaloniki, Greece. Abstract: #R29, IEJ, Vol. 38(12), December 2005.

37.”Cohesive Strength of Resilon and Other Dental Polymers.” Williams et al, Medical College of Georgia, Augusta, GA. Abstract: #OR 21, JOE, Vol. 31(3), March 2005.

38.”Clinical Performance of Resilon and Gutta-Percha at 3 and 6 Months.” Heffernan et al., University of North Carolina, Chapel Hill, NC. Abstract: #PR11, JOE, Vol. 31(3), March 2005.

39.”Comparison of Lateral and Vertical Condensation techniques Using Resilon: A Scanning Electron Microscopy Study.” Liu and Williamson, University of Iowa, Iowa City, IA. Abstract: #PR16, JOE, Vol. 31(3), March 2005.

40.”Comparison of Microleakage of Two Obturation Materials.” R. Raina et al., Medical College of Georgia, Augusta, GA. Abstract: #OR18, JOE, Vol. 31(3), March 2005

41.”Characterization of Tubule Penetration Using Resilon: A Soft-Resin Obturation System,”ABSTRACT: 2005 IADR/AADR/CADR 83 rd General Session & Exhibition L.P. Benzley, J.C.-H. Liu, and A.E. Williamson, University of Iowa , Iowa City, USA

42.”Comparison of Apical Leakage between Canals Filled with Gutta-Percha/AH-Plus and the Resilon/Epiphany System, When Submitted to Two Filling Techniques.” Verissimo DM, Sampaio do Vale M, Monteiro AJ. J Endod. 2007 Mar;33(3):291-4.

43.”Cytotoxicity of Epiphany and Resilon with a root model.” Susini G, About I, Tran-Hung L, Camps J. Int Endod J. 2006 Dec;39(12):940-4.

44.”Clinical application of an adhesively bonded fiber post and Resilon.” Shipper G, Lopez L. Pract Proced Aesthet Dent. 2006 Apr;18(3):S12-7.

45.”Comparison of the sealing of Resilon, Pro Root MTA, and Super-EBA as root-end filling materials: a bacterial leakage study.” J Endod. 2006 Apr; 32 (4): 324-7.

46.”Detectability of Residual Epiphany and Gutta-Percha after Root Canal Treatment using a Dental Operating Microscope and Radiographs — An Ex Vivo Study.” Schirrmeister et al. Albert-Ludwigs University, Germany. IEJ, Vol. 39, No. 7, July 2006: pp558-65.

47.”Dentinal bonding reaches the root canal system.” Teixeira et al., J. Esthet. Restor. Dent., Vol. 16(6), November 2004.

48.”Disinfection of artificially contaminated Resilon cones with chlorhexidine and sodium hypochlorite at different time exposures.” Dumani A, Yoldas O, Isci AS, Koksal F, Kayar B, Polat E. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Mar;103(3):e82-5.

49.”Effects of Sodium Hypochlorite and Chlorhexedine Solutions on Resilon Cones: An Atomic Force Microscopy Study.” Isci, Yoldas and Dumani. Cukurova University, Turkey. JOE, Vol. 32, No. 10, October 2006: pp 967-9.

50.”Effect of Intracanal Medicament on the Sealing Ability of Root Canals Filled with Resilon.” Wang, Debelian and Teixeira. University of North Carolina. JOE, Vol. 32, No. 6, June 2006: pp532-6.

51.”Efficacy of Retreatment Techniques for a Resin-Based Root Canal Obturation Material.” Ezzie et al. Baylor College of Dentistry. JOE, Vol. 32, No.4, April 2006:pp341-4.

52.”Effect of Calcium Hydroxide-Based Medicaments on Epiphany’s Bonding Strength to Root Canal Dentin.” Barbizam et al., University of North Carolina, Chapel Hill, NC. Abstract: #PR34, JOE, Vol. 32(3), March 2006.

53.”Effect of Lipase on the Yield Strength of Thermoplastic Endodontic polymers.” Oblad et al., U.S. Army Dental Activity, Ft. Gordon, GA and Medical College of Georgia, Augusta, GA. Abstract: #OR51, JOE, Vol. 32(3), March 2006.

54.”Effect of Various Endodontic Irrigants on the Shear Bond Strength of Epiphany Sealer to Dentin.” Wachlarowicz et al., U.S. Army Dental Activity, Ft. Gordon, GA and Medical College of Georgia, Augusta, GA. Abstract: #OR29, JOE, Vol. 32(3), March 2006.

55.”Effectiveness of Hand and Rotary Instrumentation for removing a New Synthetic Polymer-Based Root Canal Obturation Material (Epiphany) During Retreatment.” Schirrmeister et al., IEJ, Vol. 39(2), February 2006. Int Endod J. 2006 Feb;39(2):150-6.

56.”Epiphany – Influence of Sealer Placement and Cone taper on Microleakage.” Roggendorf et al., University of Erlangen-Nuremberg, Erlangen, Germany. Abstract: #R32, IEJ, Vol. 38(12), December 2005.

57.”Enterococcus faecalis type strain leakage through root canals filled with Gutta-Percha/AH plus or Resilon/Epiphany.” Baumgartner G, Zehnder M, Paque F. J Endod. 2007 Jan;33(1):45-7

58.”Evaluation of microleakage of roots filled with different techniques with a computerized fluid filtration technique.” Sagsen B, Er O, Kahraman Y, Orucoglu H. J Endod. 2006 Dec;32(12):1168-70

59.”Fluid Filtration Comparison of Gutta-Percha Versus Resilon: A New Soft Resin Obturation System” Stratton et. al., Abstract #20, 31(3), March 2005. J Endod. 2006 Jul;32(7):642-5.

60.”Fracture resistance of simulated immature teeth filled with resilon, gutta-percha, or composite.” Wilkinson KL, Beeson TJ, Kirkpatrick TC. J Endod. 2007 Apr;33(4):480-3. Epub 2007 Jan 22.

61.”Fracture resistance of roots endodontically treated with a new resin filling material.” Teixeira FB, Teixeira EC, Thompson JY, Trope M. J Am Dent Assoc. 2004 May;135(5):646-52.

62.”Geometric factors affecting dentin bonding in root canals: a theoretical modeling approach.” Tay FR, Loushine RJ, Lambrechts P, Weller RN, Pashley DH. J Endod. 2005 Aug;31(8):584-9

63.”Initial In Vitro Biological Response to Contemporary Endodontic Sealers.” Bouillaguet Et Al. University of Geneva and Medical College of Georgia. JOE, Vol. 32, No. 10, October 2006: pp 989-92.

64.”Interfaces in Soft Resin Obturated Root Canals” ABSTRACT: 2005 IADR/AADR/CADR 83 rd General Session & Exhibition D.J. Alongi*, R. Caicedo, R. Moiseyeva, K. Vo, and N.K Sarkar, Louisiana State University, Health Sciences Center, School of Dentistry, New Orleans, USA

65.”Ideal obturation using synthetic root-filling systems: coronal sealing and fracture resistance.” Teixeira FB. Pract Proced Aesthet Dent. 2006 Apr;18(3):S7-11.

66.”Interfacial strength of Resilon and gutta-percha to intraradicular dentin.” Gesi A, Raffaelli O, Goracci C, Pashley DH, Tay FR, Ferrari M. J Endod. 2005 Nov;31(11):809-13.

67.”Long Term Evaluation of Coronal Leakage of Root Filled Teeth Using Different Sealers.” Farmakis et al., University of Athens, Athens, Greece. Abstract: #R35, IEJ, Vol. 38(12), December 2005.

68.”Leakage Analysis of Three Modern Root Filling Materials after 90 Days of Storage.” Wegerer et al., University of Erlangen-Nuremberg, Erlangen, Germany. Abstract: #R31, IEJ, Vol. 38(12), December 2005.

69.”Leakage along apical root fillings with and without smear layer using two different leakage models: a two-month longitudinal ex vivo study.” Shemesh H, Wu MK, Wesselink PR. Int Endod J. 2006 Dec;39(12): 968-76

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