Review Article

Adhesive Dentistry and Endodontics. Part 2: Bonding in

Abstract
One of the recent trends in endodontics has been the
development of bonded obturating materials, in an
effort to provide a more effective seal coronally and
M icroorganisms are the cause of pulpitis and apical periodontitis (1–3) as well as
failure in endodontic treatment (3, 4). One goal of endodontic treatment is the
reduction or elimination of microorganisms from the root canal system. Complete
apically. Materials utilizing dentin adhesive technology elimination of microorganisms can not be achieved consistently with current treatment
have been borrowed from restorative dentistry and methods, however (5, 6). Therefore, an additional goal of treatment is to seal the root
adapted to obturating materials. This review discusses canal system from the outside environment with an obturating material and entomb any
the obstacles to effective bonding in the root canal residual microorganisms. None of the current dental materials provide a hermetic, leak
system, the progress that has been made, and possible proof seal, however (7, 8).
strategies for improved materials in the future. Much of Gutta-percha has been the traditional endodontic obturating material, used in
the literature reviewed and many of the principles combination with a sealer containing zinc oxide and eugenol, calcium hydroxide, or
discussed are taken from the restorative dentistry lit- epoxy resin. In recent years obturating materials and sealers have been developed based
erature and applied to the unique environment of the on dentin adhesion technologies borrowed from restorative dentistry, in an attempt to
root canal system. (J Endod 2006;32:1125–1134) seal the root canal system more effectively. Also, posts are often bonded in place.
Effective bonding in the environment of the root canal system is a challenge, however,
Key Words because of anatomy and limitations in the physical and mechanical properties of the
Adhesive dentistry, dentin bonding, endodontic sealers, adhesive materials. A previous article provided an overview of adhesive dentistry as it
obturation, radicular dentin relates to endodontics and the restoration of access cavities (9). This review will discuss
how the unique environment of the root canal system presents a particular challenge for
bonded materials, but also has promise for more effective obturating materials. It will
Address requests for reprints to Dr. Richard Schwartz, 7
discuss the limitations of current materials, the progress that has been made, and
Kings Castle, San Antonio, TX 78257. E-mail address: sasunny@ possible strategies for the future.
satx.rr.com.
0099-2399/$0 - see front matter
Copyright © 2006 by the American Association of
Endodontists.
Bonding Resin to Dentin
doi:10.1016/j.joen.2006.08.003 Current theory of dentin bonding was first described by Nakabayashi et al. in 1982
(10). They described a process that is still used with some of today’s adhesive materials.
It is a three-step process that allows hydrophobic (water hating) restorative materials to
adhere to the wet dentin surface. An acid is applied to the dentin surface and rinsed off,
removing the smear layer, demineralizing the superficial dentin, and exposing the
collagen matrix. A resinous material, incorporated in a volatile liquid carrier, such as
acetone or alcohol, is then applied to the demineralized dentin. The carrier penetrates
the moist dentin surface and carries the resinous material into the collagen matrix and
dentinal tubules. The dentin is then air dried to evaporate the carrier, leaving the
resinous material behind. The volatile liquid/resinous material is known as the primer.
An unfilled or lightly filled resin is then applied to the dentin surface and light cured.
This material, known as the adhesive, co-polymerizes with the resin already in the
collagen matrix, locking it onto the dentin surface (10 –13), and providing a hydro-
phobic surface for co-polymerization with hydrophobic restorative resin materials. The
resin infiltrated collagen matrix is commonly referred to as the hybrid layer. With most
products, the hybrid layer is between 2 and 5 ␮m in thickness (14).
Hybridization is the primary process used today to bond hydrophobic restorative
resin materials to dentin. Contrary to common belief, the dentinal tubules make only a
minor contribution to dentin adhesion. The majority of the retention is provided by micro-
mechanical retention from the collagen matrix in the intertubular dentin (15–17). One study
quantified the contribution of the dentinal tubules at 15% (18). Whereas micromechanical
retention is believed to be the primary source of retention, there is also a small amount of
chemical interaction with dentin with some adhesive systems (19).

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Review Article
Successful dentin adhesives have been available since the late a favorable geometry with a ratio of approximately 1:1. There are few if
1980s. At that time most of them utilized the three-step system similar to any walls that directly oppose each other and approximately one-half of
the one described by Nakabayashi et al.: etch and rinse, primer, adhe- the resin surface is not bonded. In the root canal system, the ratio might
sive. These are currently described in the dental literature as three-step be 100:1 (35). Virtually every dentin wall has an opposing wall and
etch and rinse and are marketed as fourth generation adhesives. Sub- there are minimal unbonded surfaces. Any ratio greater than 3:1 is
sequent simplified adhesives were developed that combined some of the considered unfavorable for bonding (45). Because of this unfavorable
steps and are described as two-step etch and rinse or fifth generation; geometry, it is not possible to achieve the gap free monoblock suggested
two-step self-etch or sixth generation; and one-step self-etch or seventh in the advertisements of some products. Interfacial gaps are virtually
generation. These materials all depend on micro-mechanical interlock- always present in bonded restorations in restorative dentistry (46),
ing from the collagen matrix for retention. The three-step products are obturating materials (47), and bonded posts (48, 49), and gap forma-
still the most effective and simplifying the process by combining steps tion increases with time (50).
has generally proven to result in an inferior bond (14, 20 –27). Most of Another limitation of dentin bonding is deterioration of the resin
the current adhesive research is with the simplified adhesives and they bond with time. This is a process that is well documented in vitro
will probably continue to improve with time. The most promising data (23–26, 51–58) and in vivo (59, 60). Loss of bond strength is first
so far for simplified adhesives has been with the two-step self-etching detectable in the laboratory at 3 months (26). Interfacial leakage in-
adhesives (28 –29). creases as the bond degrades (61, 62). Functional forces have been
The only current resin obturating sealer that utilizes dentin adhe- shown to contribute to the degradation of the resin bond in restorative
sive technology is Epiphany (Pentron Clinical Technologies, Walling- applications (26, 63– 65). This is also undoubtedly true in the root
ford, CT). It is used like a two-step self-etching (sixth generation) ad- canal system where torsional and flexural forces stress the dentin/resin
hesive system. An acidic primer is applied to the dentin surface. It interface repeatedly during function and parafunction. Repeated stress
penetrates through the smear layer and demineralizes the superficial causes microfractures and cracks within the resin (26). Unpolymerized
dentin. The acid and primer have been combined, eliminating one step resin also contributes to the breakdown of the bond (26). The three-
in the process. The acidic primer is air dried to remove the volatile step etch and rinse adhesives exhibit less degradation than the other
carrier and then Epiphany sealer, a dual-cured resin cement is applied adhesives (26, 57, 58, 66). To be clinically relevant, published bond-
and polymerized. The smear layer is incorporated into the hybrid layer. ing studies should report results with no less than 3 months of aging.
Adhesive materials are frequently compared using bond strength For in vitro studies, some method of simulating functional forces
and microleakage tests. Bond strength refers to the force per unit area should be used.
required to break the bond between the adhesive material and dentin. It One of the most important factors in the strength and stability of the
is usually described in megapascals (MPa) that is Newtons per square resin/dentin bond is the completeness of resin infiltration into the de-
millimeter. Typical dentin bond strengths reported for adhesive resins mineralized dentin. If the resin doesn’t completely infiltrate, fluid move-
are 20 to 30 MPa, although they can be much higher depending on the ment between the hybrid layer and unaffected dentin speeds the degra-
testing methods. Microleakage is perhaps more important for endodon- dation of the bond (26, 67–70). Water ingress can cause hydrolysis and
tic applications than bond strength. Even if a material has relatively low plasticizing of the resin components. Plasticization is a process in which
bond strength to dentin it may be a good obturating material if it is fluids are absorbed by the resins, causing them to swell, resulting in
effective in preventing microleakage. None of the current adhesive ma- degradation of their mechanical properties (26). Hydrolysis can break
terials provide a leak proof seal, however (8, 22, 30 –33). A more the covalent bonds within collagen fibrils and the resin polymers (51).
complete discussion of dentin and enamel bonding can be found in part This process is enhanced by enzymes released by bacteria (71) and
1 of this review (9). from the dentin itself (67). The breakdown products diffuse out of the
interfacial area, which weakens the bond, and allows more fluid to
ingress. Collagen degradation is thought to occur via host-derived ma-
The Limitations of Dentin Bonding trix metalloproteinases (MMPs) that are present in dentin and released
From the restorative literature, we know that dentin bonding ma- slowly over time (67). MMPs are also released by bacteria, along with
terials are widely used, but have limitations. Many of the limitations are other enzymes (67, 71), but bacteria are not necessary for collagen
related to polymerization shrinkage. When resin based materials poly- degradation to occur (67). It is interesting to note that chlorhexidine is
merize, individual monomer molecules join to form chains that contract an MMP inhibitor that can arrest degradation of the hybrid layer in vivo
as the chains grow and intertwine, and the mass undergoes volumetric (72). It may be possible to incorporate MMP inhibitors in future adhe-
shrinkage (34). Resin based restorative materials shrink from 2 to 7%, sive resin systems.
depending on the volume occupied by filler particles and the test The adhesive systems that are most effective demineralize to the
method (34 –37). The force of polymerization contraction often ex- proper depth and then infiltrate to the full depth of demineralization
ceeds the bond strength of dentin adhesives to dentin, resulting in gap (51). Prolonged etching times may create a demineralized zone that is
formation along the surfaces with the weakest bonds (26, 34, 35, 38 – too deep for effective resin infiltration (51, 73, 74), resulting in a
40). Separation often occurs within the hybrid layer (41), but can occur weaker bond and accelerated degradation. A demineralized zone of
in other areas. Resins in thin layers generate very high forces from about 10 ␮m was found when a 5-minute soak of MTAD was used
polymerization contraction (34, 38, 41, 42). before bonding procedures (75), resulting in incomplete resin infil-
The root canal system has an unfavorable geometry for resin bond- tration. The effectiveness of demineralization/infiltration varies with ev-
ing (43). Configuration factor or C-Factor, the ratio of bonded to un- ery dentin adhesive system, which helps to explain the great variability
bonded resin surfaces (35), is often used as a quantitative measure of reported in the literature.
the geometry of the cavity preparation for bonding. The greater the
percentage of unbonded surfaces, the less stress is placed on the
bonded surfaces from polymerization contraction. The unbonded sur- Glass-Ionomer Cements
faces allow plastic deformation or flow within the resin mass during Traditional glass-ionomer cements consist primarily of alumina,
polymerization (35, 44). A class 5 cavity preparation, for example, has silica, and polyalkenoic acid and are self-curing materials. They are the

1126 Richard S. Schwartz JOE — Volume 32, Number 12, December 2006
 Review Article
only restorative materials in which the primary bonding mechanism How is the Endodontic Environment Different for
is chemical (76). They form an ionic bond to the hydroxyapatite at Bonding Than the Restorative Environment?
the dentin surface (77) and obtain micromechanical retention to In addition to the unfavorable geometry, as previously discussed,
the etched surface of the hydroxyapatite crystals (78, 79). Like there are several other factors that make bonding in the root canal
adhesive resins, glass-ionomer cement loses bond strength over system a challenge.
time (79). Some glass-ionomer materials possess antimicrobial
properties (80 – 82). The Problems of Using Adhesive Materials Deep in the Root
When placing glass-ionomer cements, the surface is cleaned and Canal System
then treated with a weak acid (76, 79). The acid removes debris from Performing the bonding steps is problematic deep in the root canal
the dentin surface, removes the smear layer, and exposes hydroxyapatite system. Uniform application of a primer or adhesive in the apical one-
crystals. It etches the hydroxyapatite, but there is minimal dissolution (76, third is difficult at best and the primer must be applied properly for
78). Because glass-ionomer cements rely on ionic bonding to the hydroxy- effective bonding. Once the primer is applied, the volatile carrier must
apatite, strong acids should be avoided because they cause almost total be evaporated. This can also be problematic in the apical one-third. It is
elimination of mineral from the dentin surface (83). Removal of the difficult, and probably a bad idea, to blow air into the apical one-third.
smear has generally been shown to improve the bond of glass-ionomer Application and drying of the primer with paper points, as recom-
cement to dentin (79, 84, 85). mended by at least one manufacturer, is probably not very effective for
Most of the current glass-ionomer restorative materials contain either task. If the acetone or alcohol carrier is not completely removed,
resin and are referred to as resin modified glass-ionomer materials. the bond is adversely affected (108). An in vitro post study by Bouil-
They contain a light-cure resin that provides for rapid polymerization on laguet, et al. (98) reported lower bond strengths were achieved bonding
the surface. Most resin modified glass ionomers utilize the same bond- in the root canal system than to flat prepared samples of radicular
ing mechanisms as traditional glass ionomers. dentin. These results are not surprising for the reasons previously dis-
Several glass ionomer-obturating materials are available and more cussed. More effective methods must be developed to deliver the acid
are in development. Ketac Endo (3M ESPE, St. Paul, MN), a traditional and primer deep in the root canal system and to remove the volatile
glass-ionomer material has been around the longest and has a small carrier. In teeth with small, complex anatomy, this may not be possible.
following. Contact between components in adhesive materials and the
apical tissues is a concern. The affects are unknown from extrusion
of solvents such as acetone, unpolymerized resin or HEMA (hy-
droxyethyl methacrylate, which can be hyperallergenic and is con-
Is Radicular Dentin Different Than Coronal Dentin? tained in many primers).
Several investigators have studied the composition and structure of
radicular dentin and found minor differences from coronal dentin. In The Problems With Dual-Cured and Self-Cured Resins
the apical one-third of the root, there are fewer dentinal tubules (86 – Because penetration with a curing light is limited in the root canal
88) and consequently, less resin tag formation during bonding proce- system, dual-cured or self-cured resin adhesives must be used. Dual-
dures (87, 89). This is potentially a positive feature if the adhesive cured resins contain components that provide rapid light polymeriza-
materials can be applied effectively, because more intertubular dentin is tion in those areas where the curing light penetrates effectively and a
available for hybridization (87). As previously stated, resin tags make slower chemical polymerization in those areas where the light is not
only a minor contribution to bond strength (15–18). In some apical effective. Adhesives and sealers that contain a self-cure component are
areas the dentin is irregular and devoid of tubules (86). After bonding a mixed blessing, however.
procedures, the hybrid layer was found to be thinner in the apical areas On the plus side, the slower polymerization process allows the
by some authors (87, 90, 91) and no difference was found by others material to flow in the pregel stage, which provides some stress relief
(89, 92, 93). Results varied depending on the products used (89). from polymerization contraction at the resin/dentin interface (40, 109).
These differences appear to be of little importance because thickness of Self-cured resins have less conversion of monomer to polymer than
the hybrid layer has not been shown to influence adhesive capacity (21, light-cured resins, which lessens the forces from polymerization con-
94, 95). Some authors have reported higher bond strengths to dentin in traction (40) and air bubbles, incorporated into the resin during the
the apical one-third (88, 96, 97), some have reported lower bond mixing process, provide a stress relief mechanism (110) by increasing
strengths (91, 98, 99), and some have reported little difference (90, 93, the surface area of resin that is not bonded to dentin (41). Of course,
100 –104). The results vary depending on the adhesive system used unpolymerized resin and air bubbles have negative effects on the me-
(90, 91, 93, 101, 103). Two studies reported higher bond strengths in chanical properties and chemical stability of the resin.
From the restorative literature, we know that the self-etching ad-
the pulp chamber than the cervical dentin (105, 106). High initial bond
hesive systems generally have low bond strengths when used with self-
strengths (23.5 MPa) are achievable with radicular dentin (90), and
cured composites or dual-cured composites that have not been light
are comparable to those reported for coronal dentin. A recent article activated (104, 111–114). This varies somewhat by product, however
reported that radicular dentin in the apical third is often sclerotic and (103), and was not a universal finding (101). Reduced bond strengths
the tubules are filled with minerals that resemble those from peritubular with self-etching materials have also been reported with bonded posts
dentin (107). This process starts in the third decade of life and (115). There are two aspects to this problem.
progresses in an apical-coronal direction. It is a potential impediment Self-cured resins contain tertiary amines in the catalyst, which
to effective dentin adhesion and will require further investigation, but as initiate the polymerization reaction and have a high pH. Loss of bond
long as there is adequate intertubular dentin available, it may not prove strength may result when an acidic primer is used. Because the acid is
to be a significant finding. At this point in time, viewing the literature as not rinsed off after application, residual acid can partially neutralize the
a whole, there appear to be no compositional or structural impediments high pH amines in the self-cured component of the adhesive or sealer,
to bonding to radicular dentin. making them less effective in the chemical polymerization process

JOE — Volume 32, Number 12, December 2006 Adhesive Dentistry and Endodontics: Part 2 1127
Review Article
(112, 113, 116, 117). The buffering properties of dentin help to lessen Eugenol
this effect, especially with the weak self-etching primers. Dual-cured Eugenol is one of many substances that inhibits the polymerization
composites exhibit bond strengths comparable to light-cured compos- reaction of resins (143) and can interfere with bonding (97, 102).
ites in the areas that are effectively light-cured (104), because they are Eugenol containing endodontic sealers can be a problem with bonded
not dependent on the basic amines for polymerization. posts. The effects of the eugenol can be minimized if the proper proce-
The second problem with the self-etching adhesive systems when dures are followed, however. The canal walls should be cleaned me-
used with self- or dual-cured resins is that they are highly hydrophilic chanically and then scrubbed with alcohol or a detergent to remove all
and act as permeable membranes. The chemical polymerization pro- visible signs of sealer. Sealers and temporary cements leave behind an
cess is slow. Epiphany sealer, for example, takes 30 minutes to poly- oily layer of debris that must be removed before bonding procedures
merize in the deep, self-cured areas (118). Extended setting time for (144, 145). Once the dentin surface is clean, an etch and rinse adhesive
self-cured resins is beneficial for stress relief, but the prolonged time system should be used. The strong acid demineralizes the dentin
allows diffusion of moisture from the dentin through the hydrophilic surface to a depth of about 5 ␮m and removes the eugenol rich
primer, which creates water blisters along the interface with the slow layer. Studies have shown that the three-step etch and rinse proce-
polymerizing resins. This moisture contamination reduces bond dure allows effective bonding to eugenol contaminated dentin sur-
faces (146, 147). An etch and rinse adhesive system should be used,
strength and facilitates leaching of water-soluble components from the
because the self-etching systems incorporate the eugenol rich smear
resin, which may further contribute to the breakdown of the bond
layer into the hybrid layer, rather than removing it. Eugenol has no
(20, 113, 116, 119 –121). This phenomenon occurs in vitro and in effect on glass-ionomer cements (148).
vivo (119), and in vital as well as endodontically treated teeth
(121). It is not a problem in the areas that are light polymerized Other Barriers to Effective Bonding
(104) or with the three-step etch and rinse adhesives (121). Poly-
Effective dentin bonding requires a surface that is free of debris
merization of an unfilled resin layer over the acidic primer reduces and remnants of the pulp. Studies have shown that significant portions of
the problems of permeability (122). the canal walls are not touched by endodontic instruments in the shap-
ing process (149, 150) and our irrigants are not totally effective in those
The Problems With Irrigating Solutions and Medicaments unprepared areas either (6). Dentin surfaces that are covered with
Sodium hypochlorite is commonly used as an endodontic irrigant debris and remnants of pulp tissue are not likely to achieve effective
because of its antimicrobial and tissue dissolving properties. It causes bonding.
alterations in cellular metabolism in microorganisms and destruction of Calcium hydroxide paste is sometimes placed in the root canal
phospholipids and degradation of lipids and fatty acids. Its oxidative system between appointments for its antimicrobial properties and other
actions cause deactivation of bacterial enzymes (123). It is an ideal desirable effects. It is not possible to remove all the calcium hydroxide
endodontic irrigant in many ways, but causes problems when used with from the root canal system, however, before obturation (151–153).
Concerns have been expressed that residual calcium hydroxide paste
adhesive resins. Because it is a strong oxidizing agent, it leaves behind
could prevent effective bonding in some areas; that it can act as a
an oxygen rich layer on the dentin surface that results in reduced bond
physical barrier, and that the high pH may act to neutralize the acid
strengths (124 –130), and increased microleakage (131). Oxygen is primer in self-etching adhesives. A recent article by Wang et al. (154)
one of the many substances that inhibit the polymerization of resins reported no difference in microleakage with Resilon between teeth with
(132). The oxygen rich dentin surface is probably an important reason and without the use of calcium hydroxide as an intermediate dressing.
for the low bond strengths reported for adhesive resin sealers. It is Further research is needed, however, to confirm their findings.
possible to achieve normal, high bond strengths (23.5 MPa) to radic- Some clinicians use alcohol as a final rinse to aid in drying the
ular dentin under ideal conditions (90), as opposed to the low bond canals. Most dentin adhesive systems need moisture present in super-
strengths reported for adhesive endodontic sealers (⬍6 MPa). One ficial dentin to be effective (14), so a final alcohol rinse is not recom-
possible solution to this problem is the application of a reducing agent mended with an adhesive resin sealer.
to the dentin after sodium hypochlorite irrigation. Reducing agents such
as ascorbic acid and sodium ascorbate are reported to reverse the Retreatment
negative affects of sodium hypochlorite (124, 128, 131). Retreatment is always a concern with a new material. Resilon is
Other materials that are applied to dentin during endodontic pro- soluble in chloroform and other solvents, and several studies show it is
cedures have been tested for their effects on bonding. Not surprisingly, easily removed by a variety of methods (155–157). Epiphany, on the
hydrogen peroxide leaves behind an oxygen rich surface that inhibits other hand, like other resins, is not soluble in the solvents commonly
bonding (126, 127). Reduced bond strengths were also reported after used in dentistry. Removal of resin sealers from fins and accessory
the use of RC prep (Premier Dental Products, Plymouth Meeting, PA) canals or deep bifurcated canals is difficult. Removing bonded resin is
(125). Electrochemically activated water has gained a following as an likely to be that much more difficult.
irrigating solution. One of the active ingredients is hypochlorous acid, a
strong oxidizing agent also found in sodium hypochlorite (133). No loss Does Removal of the Smear Layer Matter?
of bond strength is reported from chlorhexidine use with resins (126, For a relatively small issue, this question has been studied exten-
134, 135) or resin-modified glass-ionomer materials (136). Caries sively and remains somewhat controversial. Removal of the smear layer
detector did not affect resin bond strengths (137, 138), but chloroform has generally been shown to increase bond strength to dentin for glass-
and halothane cause significant loss of bond strength (139). Sodium ionomer materials (79, 84, 85) and unbonded resin materials (158),
hypochlorite and ethylenediaminetetracetic acid (EDTA) have also been although the bond strengths are still quite low (85, 158). Removal of the
shown to degrade the mechanical properties of dentin (140 –142). smear layer is reported to reduce microleakage for most sealers (159 –
Problems posed by certain irrigating solutions and medicaments must 163). EDTA has been used for many years in endodontics for this func-
be overcome if resin bonding is to be effective in the root canal system. tion (164). Acids work equally well (142). Care must be used not to

1128 Richard S. Schwartz JOE — Volume 32, Number 12, December 2006
 Review Article
over treat the dentin surface, however (142). Removal of the smear immature teeth (187). Williams, et al., reported that neither Resilon nor
layer has additional benefit in infected teeth because bacteria are one of gutta-percha has adequate stiffness to reinforce teeth (188). Similar
its components. minor strengthening effects have also been reported for AH-26 and
Ketac Endo (189). It is doubtful that any of these findings are clinically
Current Resin and Glass-Ionomer Obturating Materials significant. The second company sponsored study reported less leakage
AH 26 and AH Plus in vitro with the Resilon system than with AH-26 after 3 weeks (175).
Three weeks is not adequate aging of the specimens, however, and the
AH 26, which was later modified to AH Plus, have been available as
root canal sealers for many years. Both are described as epoxy-resin bonds were not stressed during the storage period. These results are
sealers. They are generally placed in the canal without any dentin prep- supported by a recent Canadian study (190) but countered by a study by
aration or dentin adhesive and can be used with any obturating tech- Tay et al. (47) who found no difference in microleakage with the same
nique. Their popularity has been due, in part, to the fact that they contain materials. The third study utilized dogs and compared Resilon/Epiphany
no eugenol, which inhibits the polymerization of resins (143) and can with gutta-percha/AH26 that was intentionally contaminated with mi-
interfere with bonding (97, 102). Low bond strengths are reported for croorganisms. Teeth obturated with the Resilon system had less perira-
the epoxy resin sealers to gutta-percha (165, 166) and to dentin (6 MPa dicular inflammation after 3 months (191).
or less) (158, 165–168). Use of a dentin bonding agent improved bond Recent independent research has been somewhat unfavorable to-
strength of AH-26 (167, 169) but no improvement was shown in a study ward Resilon/Epiphany. Tay et al. reported that Resilon was susceptible
with AH Plus and Thermafil (170). In leakage studies, AH 26 and AH to alkaline (192) and enzymatic (193) hydrolysis. Surface erosion was
Plus generally performed equal to or better than other sealers (47, 162, evident in Resilon samples in as little as 20 minutes of immersion in an
171–174), although this finding was not universal (175). Removal of alkaline hydrolyzing agent (192). Similarly, surface erosion and more
the smear layer was generally found to be advantageous (158, 162, than 50% weight loss was reported when Resilon was exposed to lipase
163, 176). The use of chlorhexidine did not affect the apical seal of and esterase for 96 hours (193). Biodegradation by bacterial/salivary
AH 26 (177). enzymes and oral/endodontic bacteria is a concern for the current
formulation of Resilon. Because obturating materials are placed in the
EndoRez protected environment of the root canal system, however, it is question-
EndoRez is an endodontic sealer that is based on the urethane able whether these results have great clinical significance. Versiani et al.
dimethacrylate (UDMA) molecule, similar to many restorative resins. It reported that Epiphany was outside the acceptable range for solubility
has additives to make it hydrophilic so it can be used in the wet envi- and dimensional stability, as described by the ANSI/ADA standards
ronment of the root canal system. It is very effective in penetrating the (194), but was within the acceptable range for setting time, flow,
dentin tubules and exhibits initial close adaptation to the dentin. How- and thickness. Melker et al. reported that Resilon was found to
ever, gap formation results from polymerization shrinkage (178). exhibit no antimicrobial activity (195), despite the fact that bioac-
EndoRez does not utilize a dentin bonding system. It has been recom- tive glass is one of the components and is considered to have anti-
mended for a single gutta-percha cone technique but can be used with microbial properties.
other obturating methods. To achieve a monoblock, as advertised by the manufacturer, high
Several investigators have evaluated EndoRez. Two studies showed bond strengths are necessary between the dentin and sealer, as well as
it to be biocompatible (179, 180), whereas another, utilizing a different between the sealer and obturating material. Bond strengths of only 4 to
test, reported it to be somewhat cytotoxic (181). Very low bond 6 MPa have been achieved between Epiphany and dentin (Dr. Martin
strengths to dentin are reported for EndoRez (158), and it performed Trope, personal communication). This is similar to the bond strength
poorly in leakage studies compared to other sealers (151, 181, 182). It reported for fiber posts and resin luting agents (135). Bond strengths of
was not found to have antimicrobial properties (183). Coating gutta- less than 2 MPa are reported between Epiphany and Resilon (168, 196,
percha with resin did not prevent gap formation or leakage (184). A 197) and one study reported lower bond strengths than with gutta-
clinical study with EndoRez reported a 91.3% success rate at 14 –24 percha and AH 26 (168). This is not surprising, because unpolymerized
months (185). So far published studies have not shown a particular resin must be available in both materials to achieve co-polymerization
benefit to using EndoRez over other sealers, but as with most new (198). There is no unpolymerized resin in Resilon. A recent study
materials, research is underway to try to improve its performance. found gaps present in teeth obturated with Resilon/Epiphany as well
as gutta-percha/AH 26, and there was no difference in microleakage
Resilon/Epiphany (47). The gaps in the Resilon/Epiphany group were between Epiph-
Resilon/Epiphany (Pentron) is the only current resin-based obtu- any and the dentin wall. In the other group the gaps were between AH
rating system that utilizes a dentin adhesive. Product advertising states 26 and gutta-percha (47). None of the specimens exhibited a mono-
that it is more effective than existing obturating materials because it block. These findings challenge the concept of a monoblock and the
utilizes a resinous obturating material and an adhesive resin sealer, results of a previous study (186) that Resilon/Epiphany strengthens
creating a monoblock of dentin/adhesive/obturating material. The Re- the tooth.
silon cones consist of is a vinyl polyester material with methacrylate
polymer, glass filler particles, and opacifiers added. Its appearance and
manipulation are similar to gutta-percha. Epiphany sealer consists of a Ketac Endo
self-etching primer that is used with a lightly filled dual-cured UDMA Ketac Endo (ESPE) is a traditional glass-ionomer cement that was
sealer/adhesive. Product advertising states that this system can be used developed as an endodontic sealer, but never gained wide acceptance.
with any obturating method. It offered little benefit in leakage studies (171, 189, 199, 200) and was
The three initial published studies were sponsored by the manu- generally considered difficult to retreat. Several new obturating systems
facturer. In the first study, obturation with the Resilon system was shown that utilize glass-ionomer materials are currently entering the market-
to strengthen the teeth slightly (186). These results are countered by a place, but there is little information and no research available at this
recent independent study in which Resilon was not found to reinforce time.

JOE — Volume 32, Number 12, December 2006 Adhesive Dentistry and Endodontics: Part 2 1129
Review Article
Efforts to Overcome the Problems with 4. Radiopaque.
Resin Adhesives 5. Biocompatible.
For adhesive materials to be effective deep in the root canal system, 6. Antimicrobial.
new, innovative delivery methods are needed. Experiments are under- 7. Nonshrinking or expands 0.5% during polymerization.
way with microbrushes and micropipettes for delivering acidic primers 8. Self-adhesive.
into the apical one-third. Similarly, microsuction may be the answer for 9. Forms a stable bond to dentin that does not degrade with time
removing the volatile primer components, such as acetone, from the and function.
apical one-third. 10. Forms a bond that is not affected by oxidizing agents like sodium
The problems associated with sodium hypochlorite must be over- hypochlorite.
come for resin bonding to be effective in the root canal system. The use 11. Strengthens the tooth.
of reducing agents, as previously discussed, is one possible solution. 12. Easily removed for post placement or retreatment.
Alternative, nonoxidizing irrigants would also eliminate this problem. Unfortunately, we are not close to development of an obturating
The problems posed by dual-cured and self-cured materials must material that meets all these criteria. Some current research is
be addressed. Use of the three-step, etch and rinse adhesive systems focused on adding ingredients that expand to the current methac-
eliminates most of the problems if it can be delivered effectively. If a rylate based materials like UDMA, to offset polymerization shrink-
self-etching primer is used, the ones that utilize weak acids offer the age. Other researchers are working on obturating materials that are
most promise because residual acid is more effectively neutralized by entirely new.
the buffering effects in dentin than the strong self-etching primers. The Recent emphasis in endodontics has been on developing adhesive
problem with moisture permeability can be overcome with adhesive resin sealers, but glass-ionomer materials have several advantages over
systems that are less hydrophilic and allow polymerization of the sealer resins. They possess 9 of 12 of the above characteristics of the ideal
without the presence of moisture. With current materials, these are the sealer. They are more dimensionally stable during the setting reaction
variables that need to be manipulated to optimize bonding in the root than resins and do not generate high forces from polymerization con-
canal system. traction, so C-factor is not a big issue. From a biohazard standpoint,
Because polymerization shrinkage is a big part of the problem, glass-ionomer materials do not contain components such as acetone or
development of shrink free obturating materials would go a long way HEMA. The biggest drawback to current glass-ionomer materials is their
toward a more effective seal. Research has been underway since the hardness, making retreatment difficult.
1980s to develop shrink free restorative composites (201–205). Non- When observing the development of new adhesive products, sev-
shrinking resins would allow the adhesive bond to mature without stress eral things should be considered. With most dental products, initial
and obviate the need for high bond strengths. Even after years of re-
company sponsored research tends to be favorable, but independent
search into nonshrinking resins, none have made it to the market.
research tends to provide a more accurate picture of a product’s
However, as the physical demands on obturating materials is less
strengths and weaknesses. Scanning electron microscope (SEM) depic-
than on restorative materials, development of non-shrinking resin
tions of the bonded interface can be misleading. Although it is possible
obturating materials may be more achievable. A small amount of
to find areas that depict a perfect interface from virtually any specimen
setting expansion, in fact, would enhance the sealing properties of
with the SEM, interfacial gaps are always present somewhere in the
the material.
specimen with current materials (46 – 48). To be clinically relevant,
The ultimate obturating material would be self adhesive, eliminat-
published bonding studies should report results with at least 3 months
ing the need for a separate adhesive system and its associated problems.
of aging. For in vitro studies, some method should be used to simulate
The glass ionomers are the only self-adhesive materials currently avail-
functional forces. If these minimal criteria are not met, the results
able in dentistry but so far, they lack desirable properties for an obtu-
should be viewed with skepticism.
rating material.
Adhesive obturating materials are in the early stages of develop-
ment. Although none of the current materials appear to offer a big
Discussion advantage over traditional obturating materials, none are likely to come
A limited amount of research evidence has been published about to a disastrous end like Hydron (Hydron Technologies, Inc., Pampano
bonding in the root canal system. Most of the knowledge about adhesion Beach, FL) in the 1980s (206). Current adhesive resins used in
to dentin has been published in the restorative literature and relates to endodontics are based on restorative resins that have been used clini-
coronal dentin. An effort has been made in this review to extrapolate that cally for almost 20 years. Furthermore, resin sealers such as AH-26 have
knowledge to highlight the problems that can be expected in endodontic produced clinical success for almost 30 years.
applications. There are a number of reasons to consider using the new obturat-
In the age of adhesive endodontic products, much ado has been ing materials. Resilon, for example, handles like gutta-percha and ma-
made about gutta-percha substitutes. However, like gutta-percha, their nipulates easily. It is highly radiopaque and provides a radiographic
primary function is to occupy space. The more important issue is the look that some clinicians find desirable. Some endodontists use adhe-
sealer and its properties. The ideal obturating material would provide a sive materials to market their practices to restorative dentists who con-
monoblock, in which the root becomes a perfectly sealed, stable, solid sider themselves to be bondodontists. These potential benefits must be
mass with no gaps. If the properties of the sealer could be optimized, weighed against the additional clinical steps necessary to use adhesive
this might be possible. The ideal sealer might even eliminate the need materials, and the additional cost.
for a gutta-percha substitute. The ideal obturating material would pos- Although adhesive obturating materials have greater potential than
sess the following properties: traditional materials, at this point in their development there is no clear
benefit to their use. However, continued research and development is
1. Easy to manipulate. likely to result in improvements and in new, more effective materials.
2. Amenable to different obturating methods. The principles discussed in this review may be used to evaluate their
3. Stable in the oral environment. progress. (100)

1130 Richard S. Schwartz JOE — Volume 32, Number 12, December 2006
 Review Article
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1134 Richard S. Schwartz JOE — Volume 32, Number 12, December 2006