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ENDODONTICS

Root Canal Obturation:

An Update
Gregg Helvey, DDS, MAGD, CDT

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Endodontics
Root Canal Obturation:
An Update
Gregg Helvey, DDS, MAGD, CDT

U
ABSTRACT ntil technology can regenerate infected pulpal tissues,
they must be replaced with restorative material through
The goal of endodontic therapy is
endodontic therapy. The goal of endodontic therapy is the
the long-term functional retention of
long-term functional retention of teeth with a history of pulpal or
teeth with a history of pulpal or peri-
periapical pathology. Treatment includes total debridement of the
apical pathology. Treatment includes
pulpal tissues and shaping of the root canals to develop a fluid-tight
total debridement of the pulpal tis-
seal at the apical foramen. One of the most important steps after
sues and shaping of the root canals
canal preparation and disinfection in endodontic therapy is obtura-
to develop a fluid-tight seal at the
tion of the root canal system.1 The entire root canal system must be
apical foramen. One of the most
3-dimensionally filled as close to the cementodentinal junction as
important steps after canal prepara-
possible. To ensure an appropriate and acceptable seal, root canal
tion and disinfection in endodontic
sealers are used in conjunction with the core filling material.1 This
therapy is obturation of the root ca-
article will expand on different materials used in root canal obtura-
nal system. To ensure an appropri-
tion systems that have been part of the history of endodontics.
ate and acceptable seal, root canal
sealers are used in conjunction with
HISTORY OF ROOT CANAL OBTURATION SYSTEMS
the core filling material. This article
The history of endodontics can be traced to the 2nd or 3rd century
will review the history of obturation
BC. A skull found in the desert in Israel had a tooth with a bronze
materials used in endodontic therapy
wire in one of the root canals.2 In 1,200 to 1,300 BC, ancient
and expand on the different materi-
Egyptian papyrus suggested the “worm theory” as the source of
als that have been used in root canal
dental pain, in which worms burrowed into the tooth and caused
obturation systems.
disease, resulting in pain. This theory of the origin of dental pain
remained until Pierre Fauchard (1678-1761), considered the founder
LEARNING OBJECTIVES
of modern dentistry, debunked the worm theory in his 1728 treatise
• Review the history of obturation “Le Chirurgien Dentiste,” or “The Dental Surgeon.”3
materials used in endodontic Over the following century, numerous contributions were made
therapy. in the field of endodontics, including pulp capping and the use of
• Describe the requirements different chemical agents, such as phenol, arsenic trioxide, and
of successful endodontic formalin. Other contributions were infection control, which oc-
treatment. curred in culturing and obturation of the root canal system.4 Even
• Describe types of root canal though endodontic therapy was gaining in popularity, clinicians
sealers. rendering endodontic treatment had no way of knowing what was
taking place inside the root canal system. That changed in 1895
• Discuss biocompatibility of root with the invention of x-rays by Röntgen. Commercial dental x-ray
canal sealers. units were made available in 1919.5

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The primary objective is to achieve a

complete obturation of the root canal system
that forms a fluid-tight seal at the apical, lateral,
and coronal sections.
In the past, various materials have been gutta-percha, which then was modified by W.B.
used to fill root canals. These materials in- Johnson, where he carried the thermo-plasticized
cluded gold foil, amalgam, asbestos, iron, lead, gutta-percha on an endodontic file. This concept
bamboo, cement, copper, oxychloride of zinc, was further developed with heat softening and
paraffin pastes, plaster of paris, resin, rubber, compacting gutta-percha by McSpadden in 1979.
silver points, and even tin foil. None were ever Then in 1984, Michanowicz introduced a low
considered to be ideal in providing the goal of temperature (70° C) injectable gutta-percha.1
complete obturation of the root canal system.1
Some of the earliest attempts to provide a her- ROOT CANAL FILLING MATERIAL
metic seal of the root canal system came in the The primary objective is to achieve a complete
19th century, when Koecker used a red-hot wire obturation of the root canal system that forms a
to cauterize the pulp and fill the canal with gold. fluid-tight seal at the apical, lateral, and coronal
Edward Hudson, in the early 1800s, used gold sections.12 Failures can be caused by incomplete
foil for root canal obturation. Although gutta- mechanical debridement, persistence of bacteria
percha was discovered by John Tradescant in left in the canals, incomplete obturation, over-
1656, the introduction of gutta-percha into the and under-extension of the root canal filling, and
field of endodontics did not occur until 1843 by coronal leakage.13
Dr. William Montgomerie.6 Shortly thereafter, After shaping and cleansing the root canal
Hill developed the first root filling material in system, the canals should be filled completely to
1847, known as “Hill’s stopping.”7 The filling prevent ingress of nutrients or oral microorgan-
material consisted of bleached gutta-percha and isms. Sealer cement and a central core material
carbonate of lime and was patented in 1848. combined provide the basic elements to create
In 1867, Bowman demonstrated the use of gutta- an apical seal. The central core material acts like
percha as a filling material in an extracted molar.8 a piston that pushes the flowable sealer ahead to
Perry, in 1883, used a pointed gold wire wrapped fill voids and attach to the dentinal wall of the
with gutta-percha.9 A new version of gutta-percha canal. In most cases, the sealer is in contact with
was introduced in 1893 by Rollins, who added ver- the dentin and not the gutta-percha.14 Therefore,
milion, which was a red pigment made from mer- the biocompatibility and sealing ability of the
cury sulfide (cinnabar).10 In 1898, Gysi’s Triopaste, root canal sealer are important.
a formaldehyde paste, was introduced by Gysi.
The softening and dissolution of gutta-percha ESSENTIALS OF ROOT CANAL OBTURATION
using rosins was introduced by Callahan in 1914.11 According to the American Association of
In 1930 Elmer Jasper introduced silver points as Endodontists (AAE), there are a number of ac-
an obturation material.1 It was not until 1977 that ceptable materials and techniques for obturation
Yee et al presented a thermo-plasticized injectable of the root canal system. These include using a

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sealer alone (cement/paste/resin), using a sealer beta phase, depending on the temperature. At
with a single cone of a stiff or flexible core mate- room temperature, gutta-percha is considered in
rial, using a sealer coating combined with cold beta phase. In this phase, gutta-percha is solid,
compaction of the core material or with warm is compactible, and can be elongated. Most com-
compaction, or using a sealer coating with a mercial gutta-percha exists in the beta phase.
carrier-based core material. If beta-phase gutta-percha is heated between
Research has shown that preparation and 107° and 120° F, it will change to the alpha
disinfection of the root canal are the most im- phase (how it exists in the tree naturally).21 In
portant factors in the successful treatment of this phase, gutta-percha is sticky, runny, and
endodontic pathosis.15 Although the sealing of noncompactible, and it cannot be elongated. As
the root canal system is an essential step in the it cools, it returns to the beta phase, but with
development of an apical seal, any single seal- greater shrinkage than the degree of expansion
ing technique cannot claim to be superior in the seen during heating.1
healing success.16,17 When a solid material is heated, there is
The primary functions of the root canal fill- usually a linear increase in volume, resulting
ing material are sealing against the ingrowth from the thermal excitation of individual atoms
of bacteria, the entombment of any remaining and molecules. After cooling, the dimensional
microorganisms, and the complete obturation of change is reversible, so the volume of most sub-
the root canal, preventing the accumulation of stances is the same at any given temperature.
stagnant fluids that serve as nutrients for bac- However, this volume constancy does not ap-
teria from any source.18,19 ply to materials with crystalline phase changes.
Therefore, the volume changes occurring from
OBTURATION MATERIALS thermal manipulation must be considered and
Materials used for root canal obturation can be di- countered by a condensation procedure.1,21
vided into 3 categories: plastics (gutta-percha and Gutta-percha is available in different forms
Resilon™), solids or metal cores (silver points, and sizes and with different coatings. Sizes and
gutta-percha–coated cones, gold, stainless steel, shapes are similar to International Organization
and titanium), and cements (mineral trioxide ag- for Standardization (ISO) standards, which have
gregate [MTA] and calcium phosphate). a 2% taper from sizes 15 to 140, although tapers
Today, the most common root canal obtura- of 4%, 6%, 8%, and 10% are available. There
tion material is gutta-percha. The name gutta- are also variable tapers used in conjunction with
percha is derived from two words in the Malay specific file systems.
language: getah, meaning gum, and pertja, the Gutta-percha is used as a coating on either a
name of a tree. Gutta-percha is extracted from metallic or plastic carrier that delivers the ma-
trees of the genus Palaquium in the family terial into the canal. The gutta-percha–coated
Sapotaceae, which naturally inhabit Southeast carriers are heated in an oven designed by the
Asia.7 The substance, derived from the sap of manufacturer to provide a constant heat source.
these trees, is a biologically inert, resilient, and Other versions of gutta-percha can be found in
electrically nonconductive thermoplastic latex. a powder form that can be incorporated into a
The material has minimal toxicity and minimal resin-based sealer as well as pellets or bars that
tissue irritability, and it is the least allergenic are heated and injected into the canal. Gutta-
when contained in the root canal system.20 It is percha can also be medicated with calcium
a polymer of isoprene, which forms a rubber- hydroxide, iodoform, or chlorhexidine.1
like elastomer. It has an approximately 60% Although gutta-percha has a proven track
crystalline form, which may occur in alpha or record and is considered the “gold standard”

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The function of the sealer is to fill the spaces

or voids left between the root canal obturation
core (ie, gutta-percha cone) and the dentinal wall.

for obturation, it does not bond to the dentinal CLASSIFICATION OF ROOT CANAL SEALERS
canal wall and shrinks after cooling.22,23 In 2004, Commonly used sealers can be classified by their
Resilon was introduced as an alternative to gut- composition.29,30,33 Variations of sealer classifica-
ta-percha. It was described as a thermoplastic tions can be found in peer-reviewed literature.
synthetic polymer that contained methacrylate Group 1: Zinc oxide eugenol (ZOE)-based seal-
resin, bioactive glass, barium sulphate, and ers. These sealers are commonly used and have
bismuth oxychloride. It had an accompanying a successful track record.33 There are two forms
dual-cure resin-based root canal sealer.24 Resilon of these sealers: a mix of a powder and liquid or
contained fillers of calcium hydroxide, bismuth a two-paste preparation. ZOE sealers are anti-
oxychloride, barium glass, and silica. The total microbial and work well with heat carriers. They
filler content was 70%.25 When compared with shrink slightly when set34 and are marginally
previous resin filling materials, Resilon was soluble.35 If extruded into the periapical tissues,
considered a viable option. In cases of retreat- ZOE will resorb.36
ment, Resilon could be softened and dissolved Group 2: Salicylate-based, or calcium hydroxide-
with solvents.26 In 2014, Resilon was removed based sealers. These sealers are usually referred
from the market because the follow-up studies to by their marketed therapeutic additives instead
contradicted the in-vitro studies.27 of by their composition.32 They have antibacte-
rial properties that are dependent on dissolution
ROOT CANAL SEALERS of the material, calcium hydroxide, which then
The function of the sealer is to fill the spaces or slightly reduces their efficacy.37 The solvation of
voids left between the root canal obturation core calcium hydroxide is necessary to achieve the
(ie, gutta-percha cone) and the dentinal wall. Gutta- desired therapeutic effects.38 Calcium hydroxide
percha alone cannot seal the canal space because it sealers have been shown to have less antibacterial
has no adherence to dentin.28 Irregularities in the activity than ZOE, but they are also less toxic.39
fill and voids between the canal walls, accessory Group 3: Epoxy resin-based sealers. These seal-
canals, and minor foramina should be filled by ers have strong sealing ability; they adhere to
the sealer.29 Chemically, root canal sealers should dentin. They are antimicrobial and work well
contain antimicrobial agents that are effective im- with resin-coated gutta-percha.33 AH Plus™
mediately after placement.30 Other necessary char- (Dentsply Sirona) is considered the industry
acteristics of sealers is that they be radiopaque, are standard by which competitive manufacturing
biocompatible with periapical tissue, do not shrink will test against. Unlike its predecessor, it does
on setting, and are insoluble in host tissue fluids not release formaldehyde.40
but soluble in a solvent that allows for removal if Group 4: Silicone-based sealers. In 1972, Davis
needed.31 ISO 6876 and ADA specification No. 57 et al used an injectable polyvinyl silicone im-
require less than 3% solubility, no more than 3% pression material in prepared root canals to study
weight loss in distilled water.32 the internal anatomy of the canal. They found

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Bioceramic sealers have the potential to increase

root strength after obturation due to their
high alkalinity, biocompatibility, bioactivity,
dimensional stability, and sealing ability.
many anatomical variations, including lateral Group 6 of root canal sealers combines all sealers
canals, webbing between canals, fins, and in- that have bioactive capability. These types of
strument markings. They also reported that the sealers are often referred to as bioceramic sealers
prepared canal was very dissimilar in shape, and have been classified as separate entities by
especially in the apical third, to the instrument other authors.32,50,51 For this article, this group
used to prepare the canal.41 Similar in composi- of sealers includes calcium silicate phosphate-
tion to the polyvinyl silicone impression mate- based and calcium phosphate-based sealers and
rial, these sealers also set by additional reaction MTA-based or bioceramic sealers.
between vinyl groups, forming a polymer.42 Root canal sealers that are biocompatible,
These sealers have been shown to have clinical possess antibacterial properties, and produce
benefits in homogeneity and adaptation to the hydroxyapatite on their surfaces in the presence
dentinal walls.43 Ørstavik et al44 reported that, of phosphate-buffered saline are considered to
due to the viscosity and elastic modulus, these have bioactivity and fall into the category of bio-
silicone-based sealers absorb stress generated ceramics.52,53 The physical characteristics of these
by mastication during root flexure. Savariz et materials include nanocrystals, with diameters
al45 found that when compared with AH Plus, of 1 to 3 nm, that prevent bacterial adhesion. At
there was a significant improvement of the api- times, fluoride ions are elements of apatite crys-
cal seal. However, Elias et al46 found similar tals and have antibacterial properties.54 GuttaFlow
sealing ability between both sealers. In a newer Bioseal was mentioned in Group 4 (silicone-based
version, GuttaFlow® Bioseal (Coltene) has added sealers); however, because of the addition of a
bioactive glass calcium silicate. According to bioactive component, calcium silicate, it can also
Gandolfi et al,47 this particular sealer can pro- be classified as a bioceramic.
vide an alternative strategy for moist or bleeding Calcium silicate phosphate-based bioceramic
apices with bone defects. sealers have strong sealing ability and little reac-
Group 5: Methacrylate resin-based sealers. The tion to periradicular tissue in the case of extrusion
first methacrylate resin sealer was introduced past the apex.33 The materials are usually applied
in the mid-1970s. It was composed of 2-hy- in a prefilled syringe and have similar viscos-
droxyethyl methacrylate polymer gel that was ity to conventional sealers. Zhang et al55 found
injected into the canal without the need for a core these bioceramic sealers to have the potential
(gutta-percha). Due to handling problems and to increase root strength after obturation due to
periapical tissue irritation, it was discontinued in their high alkalinity, biocompatibility, bioactivity,
the 1980s.48 The aim to achieve a bond between dimensional stability, and sealing ability.
the dentin and sealer led to a second generation, The first bioceramic material successfully
which was a dual-cure sealer that did not require used in endodontics was MTA cement, which
a dentin adhesive.49 was introduced by Torabinejad in 1993. Except

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A permanent restoration should be placed as soon

as possible to achieve long-term success no matter
what sealer is used in the process.
for the addition of bismuth oxide and lower at the cellular and tissue level. However, bioac-
levels of calcium aluminate and calcium sul- tive sealers had a lower potential in vitro.
fate, MTA is very similar in composition to Although root canal sealers tend to exhibit a
Portland cement. Originally, Portland cement certain degree of toxicity, especially at initial
was invented and patented by Joseph Aspdin placement, the degree of toxicity decreases with
of Leeds, England. He produced the cement by the setting of the sealer. The cytotoxicity may
heating powdered limestone mixed with clay in arise from the unconverted monomers present
a furnace and then grinding the mixture into in a freshly mixed sealer. Therefore, extrusion
a powder. When mixed and set, it resembled a of the sealer into the periradicular tissue should
type of stone that was quarried on the Isle of be avoided.58
Portland; hence, it was called Portland cement.56 Komabayashi et al32 compared the biocom-
MTA meets the criteria of bioactivity by pos- patibility and cytotoxicity of various root canal
sessing osteoconductivity, osseoinductivity, and sealers. For example, they reported that ZOE
biocompatibility. Initially, MTA was introduced sealers acted as an irritant and cytotoxic agent
as an apical filling material. Since then it has and that non-eugenol sealers exhibited a lesser
been used for pulp capping, pulpotomy, apexi- inflammatory effect.60 Silicone-based sealers,
fication, root perforation repair, and root canal when compared with epoxy resin sealers, dem-
filling material.57 onstrated a lower cytotoxicity during the first 11
days after mixing.61 The investigators reported
BIOCOMPATIBILITY that methacrylate polymer demonstrated cyto-
Of all the properties of root canal sealers, bio- toxicity only during the initial stages of polym-
compatibility is one of the most important.58 erization, and even though it is considered to be
When a material in contact with human tissue the least toxic monomer used in dentistry, the
does not trigger an adverse reaction, it is said to methyl methacrylate monomer is still considered
be biocompatible.59 Fonseca et al50 conducted a cytotoxic.62 Further research with specifically
systematic review of peer-reviewed literature on designed studies will broaden understanding of
the biocompatibility of commercial root canal biocompatibility of root canal sealers.
sealers. From a review of 1,249 studies, 73 in As previously stated, the thorough clean-
vitro and 21 in vivo studies were included in the ing and shaping of the root canal is vital to
analysis. In general, studies found that root canal periapical healing. Sometimes overlooked, the
sealers produce mild to severe toxic effects, and restorative phase of an endodontically treated
several factors may influence the sealers’ bio- tooth is also critical to the success of treatment.
compatibility. These factors include the material Recontamination of the root canal system can
setting condition and time, material concentra- arise from either apical or coronal leakage. There
tion, and type of exposure. The investigators are conditions the clinician must be aware of that
concluded from the available evidence that all can promote coronal leakage. According to the
root canal sealers exhibit variable toxic potential AAE, clinicians can prevent coronal leakage

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in endodontically treated teeth through pre- milestones in endodontics: review of literature. Int J Prev
endodontic tooth preparation, thoroughness of Clin Dent Res. 2017;4(1):56-58.
the root canal obturation technique, temporary 7. Prakash R, Gopikrishna V, Kandaswamy D. Gutta-percha:
seal of the root canal system during and after an untold story. Endodontology. 2005;17(2):32-36.
treatment, the choice and integrity of the final 8. Koch CRE, Thorpe BL. History of Dental Surgery. Ft.
tooth restoration, the timeliness of the restora- Wayne, IN: National Art Publishing Company; 1910.
tion, establishment of atraumatic occlusion, and 9. Anthony LP, Grossman LI. A brief history of root-canal
long-term follow-up to ensure the integrity of therapy in the United States. J Am Dent Assoc. 1945;32(1):43-
the treatment.63 The endodontic success rate im- 50.
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tion is accompanied by a quality restoration.64 Cosmos. 1883;25:185.
11. Weinberger BW. An Introduction to the History of Den-
CONCLUSION tistry: With Medical & Dental Chronology & Bibliographic
Obturation of a root canal consists of three steps: Data. St. Louis, MO: CV Mosby Company; 1948.
shaping, cleansing, and sealing to create a fluid- 12. Callahan JR. Rosin solution for the sealing of the dentinal
tight seal. Although it has been said that shap- tubuli and as an adjuvant in the filling of root-canals. Dent
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in providing successful endodontic therapy, 13. Schilder H. Filling root canals in three dimensions. Dent
optimal success is based on the creation of an Clin North Am. 1967;11:723-744.
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the first two steps are done correctly but there is the usual suspects. Eur J Dent. 2016;10(1):144-147.
no permanent apical seal in the final step of the 15. Paqué F, Barbakow F, Peters OA. Root canal preparation
process, the outcome may be negatively affected. with Endo-Eze AET: changes in root canal shape assessed by
However, that is only half of what is required for micro-computed tomography. Int Endod J. 2005;38(7):456-
success. The coronal seal must not be overlooked 464.
after completion of root canal therapy. A per- 16. Colleagues for Excellence. Canal Preparation and Obtu-
manent restoration should be placed as soon as ration: An Updated View of the Two Pillars of Nonsurgical
possible to achieve long-term success no matter Endodontics. Chicago, IL: American Association of Endo-
what sealer is used in the process. dontists; 2016.
17. Ng YL, Mann V, Gulabivala K. A prospective study of
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lon: a review. Brit Dent J. 2011;211(2):81-88. 39. Huang FM, Tai KW, Chou MY, Chang YC. Cytotoxicity
25. Gatewood RS. Endodontic materials. Dent Clin North of resin-, zinc oxide-eugenol-, and calcium hydroxide-based
Am. 2007;15(3):695-712. root canal sealers on human periodontal ligament cells and
26. Mohammadi Z, Jafarzadeh H, Shalavi S, et al. Resilon: permanent V79 cells. Int Endod J. 2002;35(2):153-158.
review of a new material for obturation of the canal. J Con- 40. McMichen FRS, Pearson G, Rahbaran S, Gulabivala K.
temp Dent Pract. 2015;16(5):407-414. A comparative study of selected physical properties of five
27. Barborka BJ, Woodmansey KF, Glickman GN, et al. root-canal sealers. Int Endod J. 2003;36(9):629-635.
Long-term clinical outcome of teeth obturated with Resilon. 41. Davis SR, Brayton SM, Goldman M. The morphology of
J Endod. 2017;43(4):556-560. the prepared root canal: a study utilizing injectable silicone.
28. Greene HA, Wong M, Ingram TA III. Comparison of Oral Surg Oral Med Oral Pathol. 1972;34(4):642-648.
the sealing ability of four obturation techniques. J Endod. 42. Shen C. Impression materials. In: Anusavice KJ, Phillips
1990;16(9):423-428. R, Shen C, Rawls HR, eds. Phillips’ Science of Dental Mate-
29. Kaur A, Shah N, Logani A, Mishra N. Biotoxicity of rials. 12th ed. St. Louis, MO: Elsevier/Saunders; 2013:151-
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serv Dent. 2015;18(2):83-88. 43. Elayouti A, Achleithner C, Löst C, Weiger R. Homogene-
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journals/journal-of-oral-and-dental-health-research/fulltext/ 44. Ørstavik D, Nordahl I, Tibballs JE. Dimensional change
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11th ed. Philadelphia, PA: Lea & Febiger; 1988. Long-term sealing ability of GuttaFlow versus AH Plus us-
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tal Mat J. https://www.jstage.jst.go.jp/article/dmj/adv- 46. Elias I, Guimarães GO, Caldeira CL, et al. Apical sealing
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 PEER-REVIEWED
PEER-REVIEWED
2 CDE CREDITS

49. De Munck J, Vargas M, Van Landuyt K, et al. Bonding of 57. Raghavebdra SS, Jadhav GR, Gathani KM, Kotadia P.
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2010;36(3):383-399. into dentinal tubules: a confocal microscopy study. Clin Oral
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CDE Quiz
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Endodontics
Root Canal Obturation: An Update
Gregg Helvey, DDS, MAGD, CDT

1. The goal of endodontic therapy is the: 6. In most cases, what is in contact with the dentin?
A. reduction of pain. A. core material
B. long-term functional retention of teeth with a history of B. gutta-percha
pulpal or periapical pathology. C. sealer
C. preservation of alveolar bone. D. a thin layer of pulpal exudate
D. reduction of pulpal bacteria by 50%.
7. Which single sealing technique can claim to be
2. In the 2nd or 3rd century BC, a skull found in the superior in the healing success?
desert in Israel had a tooth with what in one of the A. ZOE based
root canals? B. calcium hydroxide based
A. gutta-percha C. epoxy resin based
B. bronze wire D. no single one can claim to be superior
C. gold
D. a mysterious clay-like substance 8. Gutta-percha alone cannot seal the canal space
because it:
3. “Hill’s stopping” filling material consisted of: A. has no adherence to dentin.
A. 100% pure gutta-percha. B. is incompatible with dentin.
B. phenol and copper. C. shrinks 30% over time.
C. oxychloride of zinc and paraffin paste. D. shrinks 41% over time.
D. bleached gutta-percha and carbonate of lime.
9. Recontamination of the root canal system can
4. When did Yee et al present a thermo-plasticized arise from:
injectable gutta-percha? A. only apical leakage.
A. 1907 B. only coronal leakage.
B. 1921 C. either apical or coronal leakage.
C. 1939 D. recontamination is always the result of operator error
D. 1977
10. Obturation of a root canal consists of which steps?
5. The primary objective of a root canal filling material is A. shaping
to achieve a complete obturation of the root canal B. cleansing
system that forms a fluid-tight seal at which sections? C. sealing
A. apical D. all of the above
B. lateral
C. coronal
D. all of the above

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