Bioceramics: Should It Be on Your Radar?

Well, today I wanted to talk to you a little about bioceramics.  Lately there’s been quite a few questions that have been presented to me either live or you know, through emails or phone calls, and more and more endodontists are calling with the inquiry, “Cliff, what do you think about bioceramic sealers or bioceramic root repair materials?”

Let me give you my opinion.  First of all, I’m not a material science expert, nor would I pretend to be.  I think right now what I would say is, I have no problem with the initial literature and the support in the literature endorsing or advocating bioceramics.  I think the main thing to understand is the materials are probably excellent, but where I have the problem is where I hear the word ‘bonding’. 

Let’s come back and review the same old problem that we saw with Pentron’s Resilon and now, as many of you know, that material has been removed from the market and many of the large companies have stopped selling it because it doesn’t fulfill the claims it purports to do. As a simple example, Resilon was advocated to be used as a bonding material below the orifice and it could even strengthen roots.  What we subsequently found out and it was reported in numerous articles in various peer-reviewed journals that it doesn’t bond to roots, it didn’t strengthen roots, and many of the problems that were associated could be attributable to polycaprolactone. 

Polycaprolactone is a biodegradable material that was used in medicine for decades and it would resorb away.  So any time you have a filling material that has quite a bit of fillers that are resorbable, you have to worry about how well the material, the endodontic root canal filling material, will hold up over time. 

Coming back to bioceramics… It represents like Resilon, a new material, and it’s being advocated as a convenience and as a way to get a better seal.  I think the material is good but now let me come back and review my big concern with the word ‘bonding’.  Any time we’re going to bond below the orifice, we have to ask the question, “Do we have cleaned surfaces that are amenable to achieve bond strength and actual adhesion dentistry?”  From what I can see, from looking around the world at the various articles that are coming out on how well we actually clean root canal systems, we leave a lot of residual debris.  There isn’t a file system in the world or a protocol yet developed that completely cleans root canal systems.  So, if we understand this and we know this, then it kind of puts a big question mark over the claims by some that these various bioceramics can actually bond to dentin.  If we understand that bonding can be compromised if we have residual, as an example, smear layer left on the internal walls of a shaped canal, then we’re not going to be bonding to a smear layer.  So, until I have evidence that we’re really approaching three-dimensional disinfection, then I think we should be very suspicious of any claims on bonding below the orifice.

So, back to bioceramics...  I think it represents a potential breakthrough.  I think like any new material we need to have vigorous scientific peer-reviewed science.  We need to have collaborative evidence from different universities around the world to start all shedding some light on to its efficacy.  And finally, at the end of the day, we need to ask ourselves, “Do we have a material that currently does what bioceramics is trying to do?”  The answer is, right now we have MTA, mineral trioxide aggregate, (which) has more research behind than perhaps any endodontic material ever done in the world.  MTA has had collaborative science from around the world, from multiple universities and we know we get a biological attachment.  We know the material can be placed into an environment that might be not as clean and sterile and disinfected as we would like.  We know that we can use it when there’s even some weeping on lateral strip perfs.  We can still get great seals and see attachment, and we have histology to support that.

So, before we all jump from gutta-percha to Resilon, as an example, or before we all jump from MTA to bioceramics, maybe we better go back and ask ourselves, “Is there something wrong with what we’re currently doing?”  Have conclusive proof that any given material is significantly better… It can’t even be as good as because why make the change if it’s simply as good as?  There’s some comments by some that it might be a little bit easier to handle and use chairside, but I think that’s probably mostly a myth because if you simply learn how to handle MTA, it’s readily mixable, easy to pick up, (and) can readily be brought over into the clinical field.  It can be placed deep into a root canal space, and there’s lots of ideas and techniques that I have written about and published articles about that can be found on my website to support how to mix it, how to pick it up, how to carry it, how to shepherd it into the root defect, as an example, and then how to adapt it and mold it into this space. 

So, I’m using MTA.  The bioceramics will be interesting for me to continue to look at in the future going forward, but right now, I’m not thinking that we have root canal walls universally that are all devoid of the three things we worry about and that would be pulpal remnants, bacteria when present and the related products, and finally, the smear layer itself or the debris that’s generated from our shaping files.  A lot of this debris gets pushed into the lateral anatomy, into the eccentricities off the rounder parts of canals, and it just seems odd to me that people are saying we can bond so perfectly in these environments. 

So, that will conclude my comments now on bioceramics.  Let’s stay tuned.  Let’s be a little reticent to jump into the pool head-first until we know we are dealing with the material that has stood the test of time, has supporting research from around the world, and that we can have verifiable clinical results.  Thank you very much.