Comparative evaluation of postoperative pain and healing following root canal obturation with calcium silicate and bioactive glass-based sealers to epoxy resin-based sealers: A systematic review and meta-analysis

Abstract

Aim:

To compare the postoperative pain and healing following obturation with calcium silicate and bioactive glass-based sealers to epoxy resin sealers.

Materials and Methods:

A systematic search (2018–2024) was conducted using PubMed, Cochrane, and Google Scholar, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (PRISMA). Risk of bias (RoB) was assessed using Cochrane RoB 2 tool and quality was evaluated using GRADE. Twenty-three studies were included for qualitative analysis and 11 for quantitative analysis, including meta-analysis for bioactive glass and epoxy resin-based sealers.

Results:

Meta-analysis revealed no significant difference in pain occurrence between groups at 24 h, 48 h, and 7 days. Similarly, for bioactive glass sealer, no significant difference in pain occurrence was observed at 24 h, 48 h, and 7 days.

Conclusion:

Calcium-silicate-based sealers showed comparable and satisfactory results to epoxy resin sealers regarding postoperative pain incidence and intensity. In addition, they facilitated improved healing of periapical tissues. Notably, bioactive glass-based sealer also demonstrated exceptional properties, offering enhanced benefits.

INTRODUCTION

The ultimate goal of root canal treatment is to remove infected pulp, eradicate bacteria and preserve the tooth. Epoxy resin-based sealers are considered as the gold standard due to their low solubility and good dimensional stability. However, bioceramic sealers (BC sealers) containing calcium silicate, have gained traction since the introduction of Mineral trioxide aggregate (MTA) by Dr. Torabinejad et al. in the 1990s.[1] They are hydrophilic, biocompatible, antimicrobial, and have the ability to form monoblock. BC sealers not only help alleviate the postoperative pain, owing to the release of phosphorous ions that raise the pH, reducing irritation, but they also help in healing of lesions by the formation of hydroxy-apatite like tissue.[2] Newer generation of calcium-silicate based sealers are now incorporating bioactive glass that exhibits superior properties.[3]

Postoperative endodontic pain refers to any discomfort after initiation of endodontic treatment owing to the stimulation of the nociceptors around the tooth in response to the agents passing through the apical foramen and is prevalent in 3%–53% cases. It is a multi-factorial phenomenon, dependent on various factors such as age, gender, frequency of visits, use of analgesics, condition of the periapical area, type of tooth, presence of preoperative pain, technique used for instrumentation, and protocols for irrigation and root canal filling.[4]

Sealer extrusion during obturation is often inevitable and while it is tolerated by the periapical tissues in permissible amounts, it can cause local inflammation, hinder healing, and induce pain.[5]

Since the selection of appropriate sealer can influence the incidence and intensity of postoperative pain and healing, it is of utmost importance that one acquires a better understanding in regards to the recently published clinical literature.

Hence, this is an updated systematic review and meta-analysis to evaluate the postoperative pain and healing following root canal obturation with calcium silicate-based sealers compared to epoxy resin-based sealers.

MATERIALS AND METHODS

Protocol and registration

The following systematic review was registered on the PROSPERO database (CRD42024603857) and was executed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Search strategy

An exhaustive search was executed in PubMed/MEDLINE (2018–2024), Cochrane Central Register of Controlled Trials and Google Scholar, to encompass studies published in all languages until June 2024. The electronic search technique was devised via the integration of Medical Subject Heading terms, keywords and other free terms related to the PICO question were used. The Boolean operators “AND” and “OR” were utilized to merge the phrases and build a search strategy.

Identical keywords such as “bioceramic sealer”/“calcium silicate-based sealer”, “postoperative pain”/“healing” were employed throughout all search platforms, adhering to the syntactic constraints of each database. The search phrases were modified accordingly to fit the database. Supplementary manual searches were undertaken based on the bibliography.

PICO question and eligibility criteria

The PICO criteria used to answer the following question, “Do bioceramic based sealers reduce the postoperative pain and help in healing following root canal treatment as compared to epoxy resin sealers?” was

Population (P) – Adult patients undergoing root canal treatment or retreatment

Intervention (I) – Root canal obturation using BC sealer/calcium silicate-based BC sealer

Comparison (C) – Root canal obturation using epoxy resin-based sealers

Outcome (O) – Postoperative pain incidence and/or intensity

Study design (S) – randomized clinical trials.

Inclusion criteria

Randomized clinical trials examining the postoperative pain and/or healing of patients subjected to the intervention using BC sealers compared with epoxy resin-based sealers published from 2018 to June 2024 in peer-reviewed journals were selected.

Exclusion criteria

Studies with no comparison groups, in vitro studies, animal/histological studies, cross-sectional studies, case reports or series, opinion articles, reviews, abstracts, and studies in any other language except English were not considered.

Study selection

Two independent, blinded evaluators were appointed to identify the studies meeting the eligibility criteria by sifting through the titles and abstracts, after which they independently examined the chosen studies for entire manuscript screening. Inter-reviewer reliability was analyzed with Cohen kappa (0.80). A third reviewer was appointed to eliminate any disagreements during the selection of studies between the two authors.

Data extraction process

Eligible studies provided the following data: Author name, year of publication, participants’ ages, sample size, teeth diagnosis, outcomes assessed, method of outcome assessment, intervals of pain assessment, and main findings/conclusion were independently extracted by two reviewers.

Quality assessment

Risk of bias (RoB) evaluation was carried out using the Cochrane RoB 2 revised tool for randomized controlled trials under the following domains:

1. Randomization process

2. Deviations from intended interventions

3. Missing outcome data

4. Measurement of the outcome

5. Selection of reported results.

Every eligible study was deemed as high RoB for negative domain response (red), risk of unclear bias (yellow), and low RoB for positive domain response (green). Missing data were solicited from the authors via E-mail to gather the additional details necessary for classifying the studies. When unable to obtain the required information, the articles were classified as having a RoB that was unclear.

Meta-analysis

The software STATA version 17 (Statistical Analysis software, StataCorp) was utilized to conduct the meta-analysis. The studies utilized for the quantitative analysis comprised of the following information: (1) Similar time period for pain assessment, (2) data for incidence of postoperative pain, (3) information on mean and standard deviation of pain, (4) information regarding number of medications consumed, and (5) similar method of evaluating the postoperative pain.

Meta-analysis was carried out for the incidence and intensity of postoperative pain at certain time intervals comparing epoxy resin-based sealers to BC sealers and for incidence of postoperative pain comparing bioactive glass-based and epoxy resin-based sealers.

RESULTS

Literature search

Figure 1 shows the PRISMA flowchart used for the search strategy. Initially, 1028 studies were found through the database screening with 732 duplicates. After reviewing and analyzing the titles and abstracts, 702 articles were excluded. Among the 31 studies that underwent reassessment, 2 studies lacked a comparison group, 1 study did not include AH Plus as the control group, and 5 nonpeer reviewed studies were thus excluded. Ultimately 23 studies were selected for qualitative analysis and 11 for quantitative analysis.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-analyses flowchart depicting the search strategy and study for this systematic review and meta- analysis

Characteristics of the included studies

Table 1 lists the chief features of the 23 studies included which had at least one BC sealer and an epoxy resin-based sealer for comparison.

Table 1.

Data extraction summary

Author and year	Sealers evaluated	Partici-pant age	Sample size	Teeth diagnosis	Treatment performed	Outcomes assessed	Methods of outcome assessment	Interval of pain assessment	Main findings/ conclusion
Nagpal R 2024	Nishika Bio-C Ion AH Plus	18 to 50 years	122	Symptomatic irreversible pulpitis & symptomatic apical periodontitis	Single visit RCT	Postoperative pain	VAS	6,24,48 hrs and 5, 7 days	Calcium silicate-based sealer (Nishika Canal Sealer BG and Bio-C Sealer Ion+) resulted in significantly lower levels of pain as compared to epoxy resin-based sealer (AH Plus) at 6h and 24-h interval, there was no significant difference in postoperative pain occurrence at 48-h, 5 day and 7-day period. The analgesic intake in Bio-C Sealer Ion+ group is significantly lesser than Nishika Canal Sealer BG and AH Plus group.
Nathani 2024	AH plus BioRoot RCS	Above 18yrs	89	RCT treatment required	Single visit	Postoperative pain	VAS	8,24.48 hrs	No difference was found in the levels of postoperative discomfort following a single- visit endodontic treatment of teeth with AP using a calcium silicate- based sealer (BioRoot™ RCS) when compared to a resin- based sealer (AH Plus) at 8 h, 24 h or 48 h post- treatment.
Alzoubi 2024	TotalFill BC Sealer AH Plus	16-65 yrs	194	RCT treatment required	Multiple visit	Postoperative pain	VAS	24, 72hrs and 7days	Sealer- based obturation technique with CSS was associated with simi lar post- operative pain levels and analgesics intake as WVC with RBS. Regarding post- operative pain, SBO with CSSs may be a suitable clinical alternative.
Supreet 2023	Nishika AH plus	-	40	Necrotic pulp, apical periodontitis	2 visit RCT	Postoperative pain	VAS	24,48 hrs & 7days	Bioceramic sealer (Nishika Canal Sealer BG) caused significantly less pain than AH Plus at the 24-h interval, there was no significant difference between the postoperative pain at the 48-h and 7-day duration.
Sedani 2023	Ceraseal Nanoseal	Above 18yrs	40	Symptomatic & Re-RCT cases	Single visit RCT	Postoperative pain	VAS	24,72hrs & 7 days	The study participants reported only 1% and 0.5% of “Discomfort” and “Pain” in their CS-BG-obturated teeth. These clinical findings demonstrate that CS-BG is highly biocompatible with periapical tissue thus reducing patient anxiety during root canal obturation
Buker 2023	EndoSeal MTA Sealapex	18 to 60 years	60	Symptomatic apical periodontitis	Single visit RCT	Postoperative pain	VAS	6,12,24,48 hrs and 3,5,7days	Calcium silicate– and calcium hydroxide–based root canal sealers resulted in statistically similar postoperative pain levels and the use of analgesics.
Khabiri 2023	MTA AH Plus	18-65yrs	119	Asymptomatic apical periodontitis	Single visit RCT	Postoperative pain	VAS	6,12,24,48, 72 hrs	The mean VAS scores were significantly lower in the MTA filling group than in the other group (P<0.05)
Zampirini 2023	Ceraseal AH Plus	18–75 years	85	RCT treatment required	2 visit RCT	Healing	Periapical index (PAI)	6,12,24 months	No significant difference was observed on healing outcome and survival among the two filling groups (P>0.05). The radiographical disappearance of apically extruded Ceraseal is a possible event in the first 24 months
Kim DH 2023	Endoseal TCS AH Plus	18–82 years	170	Vital teeth requiring RCT, necrosis	2 visit RCT	Postoperative pain and healing	Numerical scale 0-10 & Periapical index (PAI)	4, 24hrs and 2,3,4,5,6,7 days	No significant difference in pain intensity at any evaluated time points between the 2 groups. Teeth with a lower PAI score and a higher preoperative NRS score were more susceptible to the occurrence of moderate/intense pain after instrumentation. A higher preoperative NRS score was also found to be a significant factor in post-obturation pain. Additionally, teeth with a preoperative vital pulp exhibited a higher likelihood of experiencing post-obturation pain.
Pontoriero 2023	BIO-C sealer ION CeraSeal BioRoot AH Plus Bio	19 to 81 years	210	Symptomatic teeth, Re-RCT, necrotic	Multiple visit	Healing	Periapical index (PAI)	18 months and above	The success rate of used bioceramic sealers was not statistically significant different (99.1%, 100%, 97.5% and 100%, respectively, for CeraSeal, BioRoot, AH Plus Bio, and BIO-C SEALER ION). Nonetheless, the distribution of healed, healing, and not-healed teeth was different between teeth sealed with different materials (P<0.01).
Kim JH 2022	Endoseal TCS AH Plus	Above 18yrs	74	Necrosis, Re-RCT and vital teeth that require RCT	2 visit RCT	Postoperative pain &Healing	Numerical scale 0-10 for pain & periapical index (PAI)	4,24,48 hrs for pain and 6 months for healing	Both groups expressed identical distribution of postoperative pain. Total success rate of root canal treatment was 60.8% (45/74). The BC sealer group showed higher success rate (71.4%) than AH Plus group (51.3%), but the difference was not significant (P 5 .097). Sealer extrusion and postoperative pain were found to negatively impact prognosis of the endodontic treatment.
Cosar 2022	MTA Fillapex AH Plus	-	88	Asymptomatic irreversible pulpitis	Single visit RCT	Postoperative pain	Numerical rating scale 0-10	6,12,24,48, 72 hrs and 4,5,6,7days	MTA Fillapex showed similar success rate and post-obturation pain incidence and intensity as AH Plus sealer and can be used as a root canal sealer in asymptomatic mandibular molars with irreversible pulpitis
Song 2022	Ceraseal ADseal EndoSeal TCS AH Plus	-	80	Asymptomatic irreversible periodontitis, necrosis, apical periodontitis	2 visit RCT	Postoperative pain	VAS	7days, 30days, 90days	No significant differences in postoperative pain, void, and sealer extrusion among sealers in 1-week, 1-month, and 3-month evaluations. Collectively, calcium-silicate-based sealer with sealer based obturation may provide comparable clinical efficiency to epoxy-resin-based sealer
Aslan 2021	Endoseal MTA EndoSequence BC Sealer AH plus	-	96	Asymptomatic irreversible pulpitis	Single visit RCT	Postoperative pain	VAS	6,12,24,48 hrs and 3,4,5,6,7 days	Sealers tested were not significantly different in terms of the severity of postoperative pain after single visit root canal treatment.
Drumond 2021	EndoSequence BC Sealer Bio-C Sealer AH plus	18–60 years	330	Asymptomatic irreversible pulpitis	Single visit RCT	Postoperative pain	Visual descriptor scale	6,12,14 hrs and 7days	The occurrence of unintentional apical extrusion of calcium silicate–based root canal sealers present similar postoperative pain results compared with resin-based sealers with low-intensity pain.
Yu YH 2021	EndoSequence BC Sealer AH Plus	Above 18yrs	194	Asymptomatic irreversible pulpitis	Single visit	Postoperative pain	Numerical scale 0-10	4,24,48hrs	The intensity of postoperative pain for the two obturation techniques was equivalent at evaluated time points.
Shim 2021	Endoseal MTA AH Plus	19 to 70 years	67	RCT treatment required	Single visit RCT	Postoperative pain	VAS	Over 7 days	Endoseal MTA and AH Plus had similar effects on the incidence and intensity of postoperative pain. The obturation time was shorter when using Endoseal MTA compared to AH Plus.
Khandelwal 2020	Tubliseal Ah plus BioRoot RCS	18-60 years	63	Necrotic pulp and apical periodontitis	Two visit	Post-operative pain and healing	VAS and periapical radiograph	24,48,72hrs and 7 days Healing: 1,3,6 months	BioRoot RCS showed less postoperative pain compared to AH Plus and Tubli-Seal and showed better periapical healing compared to AH Plus and Tubli-Seal at 3- and 6-months intervals respectively.
Ferreira 2020	Endofill MTA Fillapex AH Plus	Above 18yrs	60	Pulp necrosis, apical periodontitis	2 visit RCT	Postoperative pain	Pain scale 0-4	12,24, 48hrs and 7days	Root canal filling using AH Plus, MTA Fillapex and Endofill resulted in the same postoperative pain occurrence and intensity, and need for analgesic intake.
Tan HSG 2020	TotalFill BC AH Plus	Above 21yrs	163	Vital/ non-vital requiring RCT, Re-RCT	Single visit	Postoperative pain	Numerical scale 0-5	24hrs, 72hrs and 7 days	There was no significant difference in pain experience between teeth filled using AH Plus® or TotalFill® BC sealer 1, 3 and 7 days after obturation
Fonseca 2019	Sealer Plus BC AH Plus	-	64	Necrosis	Single visit RCT	Postoperative pain	VAS	24,48,72 hrs and 7 days	No statistically significant difference was found between the groups with regard to pain level and intake of pain killer tablets (P>0.05).
Graunaite 2018	Total Fill BC AH Plus	-	13	Re-RCT, acute apical periodontitis	2 visit RCT	Postoperative pain	VAS	24,48,72 hrs and 7days	AH Plus and Total Fill perform similarly in terms of the occurrence and intensity of postoperative pain in teeth with AAP with no material extrusion beyond the apex.
Ates 2018	iRoot AH plus	18-65 yrs	160	Vital and non-vital teeth	Single visit	Post-operative pain	VAS	6,12,24,72 hrs	Although the use of different sealers did not significantly affect pain levels following root canal obturation, the iRoot SP sealer was associated with less analgesic intake than was the AH Plus sealer.

The type of teeth assessed and their diagnosis varied throughout the studies. Necrotic teeth were included in eight studies,[6,7,8,9,10,11,12,13] symptomatic cases are included in five studies,[4,12,14,15,16] five studies have treated teeth requiring re-root canal treatment,[9,12,14,16,17] six studies have treated asymptomatic cases[10,18,19,20,21,22] and 10 studies mention treating teeth that required a root canal treatment.

Eighteen studies evaluated the postoperative pain, whereas two studies evaluated only healing[12,23] and three studies evaluated both: postoperative pain and healing.[9,11,13]

The time intervals used in the studies are similar except for a few additional intervals that have been included in some studies.

Fourteen studies used Visual Analog Scale to evaluate the pain, five studies used the numerical scale,[9,11,13,17,22] one study used the visual descriptor scale[19] and one utilized the pain scale for evaluation.[7] Four studies used the Periapical Index (PAI) to assess the healing[9,11,12,23] and one study used radiographs.[13]

The treatment was performed in a single visit in 15 studies and 8 studies carried out the treatment in 2 or more visits.

Additional details were sourced from Nagpal et al.[15] on the mean and standard deviation values of postoperative pain.

Risk of bias of included studies

The eligible studies were generally comparable in methodological quality but exhibited low to high RoB across various domains. The greatest risk was linked with the randomization process, as half the studies did not detail the allocation concealment process following the generation of a random sequence. Three studies also mentioned deviations from the delivery of intended interventions. Due to loss of follow-up after the delivery of interventions, some studies were presumed to have bias. Despite this, outcomes were reported by every study in accordance with their analysis plans, leading to a low RoB in that aspect. Four studies indicated a high overall RoB. Seven studies exhibited some concerns owing to the randomization process. The findings are illustrated in Figure 2.

Figure 2.

Risk of bias table: Review authors’ evaluations of individual bias risk items for every study. Risk of bias graph: Review authors’ judgements on bias risk, presented as percentages across all included studies

Meta-analysis

Incidence of postoperative pain

This meta-analysis was performed for the incidence of postoperative pain at the time intervals of 24 h, 48 h, and 7 days, comparing the intervention (bio-ceramic sealers) with the control (AH Plus) groups. Patients reporting with the absence of pain at the time of assessment were defined as success, while patient-reporting with pain were considered as treatment failure. Risk ratio (RR) more than 1 represents results favoring the bio-ceramic sealers, i.e., more effective in pain reduction among patients undergoing the treatment.

The risk of pain occurrence did not differ significantly at 24 h (RR: 1.12; 95% confidence interval [CI] =1.02–1.24; P = 0.53; I² = 0%), 48 h (RR: 1.06; 95% CI = 0.98–1.14; P = 0.43; I² = 0%), or 7 days (RR: 0.99; 95% CI = 0.96–1.02; P = 0.95; I² = 0%) [Figure 3].

Figure 3.

Forest plot depicting comparisons of risk of occurrence of pain between bio-ceramic sealers and AH plus after 24, 48 h and 7 days post- obturation

Intensity of postoperative pain

Meta-analysis for postoperative pain intensity (mean ± standard deviation) was performed at 24, 48 h, and 7 days. Studies presenting zero values were disregarded due to potential computational issues. Analysis for the 7-day time point included a single study[24] since the others had one or both groups with zero values for mean and standard deviation.

Since this outcome was provided as continuous variables and the pain assessment scales varied across the studies, the effect measure was the standardized mean difference (SMD). SMD less than zero represents results favoring the bio-ceramic sealers, i.e. more effective in pain reduction among patients undergoing the treatment.

No differences of statistical significance were observed for the overall effect (P = 0.60; SMD = −0.16; 95% CI: −0.29–0.03; I² = 35.45%). Subgroup analysis showed no differences in all times evaluated, as presented in Figure 4.

Figure 4.

Forest plot depicting postoperative pain intensity between bio-ceramic sealers and AH Plus at 24 and 48 h and 7days

Bio-active glass versus resin-based sealers (AH plus)

Two studies, Nagpal et al. and Supreet et al.,[6,15] were identified, that compared bio-active glass and resin-based sealers for pain assessment at: 24 h, 48 h, and 7 days posttreatment. As data were summarized differently in these studies, raw data were sourced from author and utilised for meta-analysis[15] comparing the intervention (bio-active glass sealers-Nishika) with the control (AH plus) group. The absence of pain at the time of assessment was noted as success, while patient-reporting with pain were considered a treatment failure. Risk of pain occurrence at 24 h (RR: 1.36; 95% CI = 0.90–2.05; P = 0.17; I² = 47.1%), 48 h (RR: 1.09; 95% CI = 0.98–1.21; P = 0.78; I² = 0.01%), or 7 days (RR: 1.00; 95% CI = 0.95–1.06; P = 0.25; I² = 0.00%) showed no statistical difference [Figure 5].

Figure 5.

Forest plot showing comparisons of risk of occurrence of pain between bio-active glass sealers and AH plus after 24, 48 h and 7 days postoperation

DISCUSSION

The role of sealers used as an obturating material plays a crucial role in the success of the root canal treatment in relation to providing a three-dimensional seal, promoting healing and preventing reinfection.[25] Although ideal properties for sealers have been outlined by Grossman, very few exhibit all characteristics, making sealer choice crucial for treatment outcome.

This systematic review compares the incidence and intensity of postoperative pain and healing of calcium silicate based and bioactive based BC sealers to AH Plus and includes studies published until June 2024 aiming to provide an updated understanding of these sealers.

Out of the 23 studies in this systematic review, those not fulfilling the criteria of comparison with AH Plus sealer, similar time interval assessment i.e. 24 h, 48 h and 7 days and the employed measurement scale were disqualified from the meta-analysis.

This meta-analysis reports that, the incidence of postoperative pain with BC sealer compared to AH plus at 24 h, 48 h and 7 days exhibited no significant difference.

Khandelwal et al.[13] demonstrated maximum ratio values, followed by Nagpal et al.,[15] Fonseca et al.[8] and Coşar et al.[22] inferencing that lesser patients reported with pain at 24 h in the BC sealer group, favouring their use. At 48 h, the RR values were lower in comparison to 24 h among all the studies and the 7-day values were borderline since no cases reported with pain for both groups except by Coşar et al., indicating that the choice of sealer had no effect on the postoperative pain.

Data for the meta-analysis of the intensity of postoperative pain acquired by the numerical grading of pain by patients revealed that at 24 h and 48 h, no significant difference existed between BC sealers and AH Plus. However, Alzoubi et al.[24] at 7 days marginally favored the use of AH Plus. The SMD values were lesser than zero in most studies favoring the use of BC sealer, except by Drumond et al.[19] and Coşar et al.[22] that favored the use of AH plus sealer.

This review also compared the incidence of pain of bioactive glass-based sealer – Nishika Canal Sealer and AH plus at 24 h and 48 h reporting no significant difference. No patients reported with pain at 7 days in both sealer groups. It was noted that the overall number of patients reporting to the clinic with pain were lesser when bioactive glass-based sealer was used compared to AH Plus.

Studies by Kim et al.,[11] Kim et al.[9] concluded that sealer based obturation with BC sealer was a viable alternative in comparison to AH Plus but sealer extrusion had an adverse impact on healing. Contrarily, Zamparini et al.[23] reported that extrusion by Ceraseal BC sealer was undetectable in the peri-radicular area after 24 months but no change was seen when AH Plus was used. Pontoriero et al.[12] demonstrated a higher success rate of healing, additionally Khandelwal et al.[13] concluded that BC sealers showed superior healing potential at 3 months relative to AH Plus and at 6 months relative to Tubliseal. In these studies, the healing outcome was determined by PAI and referred to the condition of tooth being asymptomatic with no periapical lesion/decreased size of lesion. Presence of higher radiodensity in the peri-radicular region and slower solubility rate of the extruded BC sealers suggests their ability to promote bone formation and enhance the conduction of bone tissue, hence speeding up the healing process by absorbing minerals from the periapical tissue.

BC materials contain calcium, phosphate and silicate ions that are analogous to those identified in the dental hard tissues. They are hydrophilic in nature and after absorbing water either from dentinal tubules or root canal, undergo a hydration reaction to form hydroxyapatite.[3] They undergo an expansion as high as 0.2% effectively sealing the apex and root canal from the surrounding tissues contrary to epoxy resin sealers that exhibit shrinkage, allowing microleakage.[26]

BC sealers also provide an alkaline pH of approximately 10[27] that is conducive for osteoinductive cells and thus promote wound healing in periapical tissues; this is in accordance with the studies reviewed here.

Bioactive glass-based sealers, introduced in 2017[27] contain silicon oxide, phosphorous pentoxide and calcium oxide[3] and show potentially higher bioactivity compared to the calcium silicate-based BC sealers owing to their amorphous structure which is responsible for the rapid and structurally stronger hydroxyapatite thus exhibiting superior properties.

Postoperative pain is influenced by factors like single-visit treatment, pulpal diagnosis, and tooth location. However, inconsistent study findings prevent definitive conclusions.

This systematic review’s strength lies in its comprehensive data collection protocol, consisting solely of randomized clinical trials. This analysis used a random-effect model to account for methodological differences and heterogeneity, providing solid evidence on the researched topic.

Based on the objective of this review, the studies showed no statistically significant results in terms of incidence and intensity of postoperative pain. These outcomes are in concordance with previous systematic reviews by Mendes et al.,[6] Seron et al.[2] and Mekhdieva et al.[28] that show marginal preference towards BC sealers. AH Plus sealers usually require dry conditions and are thus linked to the liberation of unpolymerized monomers while setting that, although present in permissible amounts trigger the nociceptors and cause inflammation.[15] Subsequently, calcium silicate based sealers demonstrate reduced inflammatory marker production and excellent bioactivity, thereby minimizing the likelihood of experiencing postoperative pain.[2]

CONCLUSION

This systematic review and meta-analysis found that calcium-silicate based sealers performed similarly to AH Plus in reducing postoperative pain and promoting healing. Bioactive glass-based sealers showed superior properties and lower rates of discomfort. While no statistically significant differences were reported, BC sealers demonstrated superior biocompatibility and healing capacity, showing promise for future endodontic applications. Confirmatory clinical trials with uniform protocols are essential to reinforce these findings.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.