{"paper_id":"2fd9d1ba-dc02-4519-b03e-96475d8ff136","body_text":"Comparative Evaluation of Root Canal Obturation Techniques and Sealers in Diabetic Dentin: An in-vitro Push-Out Bond Strength Test | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Evaluation of Root Canal Obturation Techniques and Sealers in Diabetic Dentin: An in-vitro Push-Out Bond Strength Test Mevlüt Sinan OCAK, Mehmet ESKİBAĞLAR, Mustafa GÜNDOĞAR This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8960277/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study evaluated the comparative performance of different root canal obturation approaches using different sealer materials on the push-out bond strength of dentin samples obtained from patients with diabetes mellitus (DM). Methods A total of 40 single-rooted mandibular premolars were instrumented using the Reciproc R40 system and randomly assigned to four groups (n = 10 teeth each): (1) cold lateral compaction with AH Plus, (2) warm vertical compaction with AH Plus, (3) hydraulic single-cone obturation with gutta-percha and Bioserra sealer, and (4) sealer-only technique using the Bioserra bioceramic sealer. After storage at 37°C and 100% humidity for one week, 1-mm slices were prepared from the coronal, middle, and apical thirds and subjected to push-out testing. Data were analyzed using ANOVA and Tukey’s test (p < 0.05). Results Significant differences in push-out bond strength were observed among the obturation approaches employing different sealer materials (p < 0.05). Bioceramic sealers exhibited higher bond strengths than epoxy resin–based sealers, particularly in the middle and apical thirds. Hydraulic single-cone and bioceramic sealer-only approaches outperformed conventional techniques (p < 0.001), whereas no significant difference was observed between cold lateral and warm vertical compaction. Conclusions Obturation approaches employing bioceramic sealers demonstrated superior bonding in diabetic dentin, suggesting potential advantages over conventional methods within the context of diabetic dentin. Bioceramic Sealer Dentin Adhesion Diabetes Mellitus Root Canal Obturation Push-Out Bond Strength Figures Figure 1 INTRODUCTION Diabetes mellitus (DM) is a complex multisystemic metabolic disorder projected to affect nearly 853 million people by 2050. Currently, more than 589 million adults aged 20–79 years live with DM worldwide, reflecting a significant global health burden [ 1 ]. DM is characterized by persistent hyperglycemia and arises from a combination of genetic and environmental factors [ 2 ]. It exerts systemic effects on multiple organs and tissues, including the oral cavity [ 3 ]. Previous studies have shown that poor glycemic control can negatively affect the dental pulp, connective tissues, and cellular structures, thereby compromising oral health [ 4 – 6 ]. Dentin, a mineralized tissue composed of approximately 70% inorganic material, 20% organic matrix, and 10% water, is highly relevant for endodontic treatment [ 7 ]. DM alters the trace element composition of dentin—particularly strontium, magnesium, zinc, and selenium—within the hydroxyapatite structure. These changes may affect the crystallinity and physicochemical characteristics of the mineral phase, potentially weakening the biomechanical properties of dentin, reducing microhardness, lowering fracture resistance, and impairing adhesion capacity of root canal filling materials [ 8 , 9 ]. Given these substrate alterations, the interaction between dentin and obturation materials may be material-dependent. Calcium silicate–based bioceramic sealers release calcium ions and promote biomineralization at the sealer–dentin interface, resulting in the formation of hydroxyapatite-like interfacial structures and chemical interactions with the inorganic phase of dentin [ 10 – 12 ]. Therefore, in mineral-altered diabetic dentin, it may be hypothesized that bioceramic sealers may establish enhanced substrate interactions through ionic exchange and interfacial mineral deposition compared with epoxy resin–based sealers, which rely predominantly on micromechanical retention and limited chemical bonding [ 12 ]. This potential difference in the bonding mechanism may be particularly relevant in structurally compromised dentin affected by chronic hyperglycemia [ 9 , 13 ]. Root canal obturation aims to achieve a fluid-tight seal along the root canal system, commonly using gutta-percha (GP) in combination with a sealer. Traditional techniques, such as cold lateral compaction, are still widely used but have limitations, including insufficient adaptation to canal walls and potential root fractures due to microcrack formation. Warm vertical compaction improves adaptation but remains technique sensitive [ 14 , 15 ]. In contrast, newly developed calcium silicate–based bioceramic sealers, such as Bioserra, which is a premixed sealer containing tricalcium silicate and dicalcium silicate as bioactive components, together with calcium aluminate, calcium aluminum oxide, tricalcium aluminate, and tantalum as radiopacifiers, have demonstrated superior push-out bond strength compared to resin-based sealers in healthy dentin [ 16 ]. However, their performance in structurally compromised diabetic dentin is unclear. One of the main objectives of root canal obturation is to reinforce the root dentin and increase its resistance to fracture [ 17 ]. It has been suggested that materials that adhere to the dentin surface can contribute to strengthening the remaining tooth structure [ 18 ]. The push-out bond strength test is widely used to evaluate the adhesion between obturation materials and canal walls because of its simplicity and reproducibility [ 19 ]. This test reflects a combination of frictional forces, molecular interactions, and chemical bonding between the materials and dentinal walls [ 20 ]. A review of the available literature indicates that, although several studies have assessed the bonding ability of individual materials, such as mineral trioxide aggregate (MTA) or specific sealers, in diabetic dentin [ 13 , 21 ], limited evidence exists regarding how different obturation techniques influence bond strength in this altered substrate. Most previous investigations have focused primarily on material properties rather than on technique-dependent variables. Furthermore, the current literature highlights the limited and heterogeneous nature of data concerning the mechanical performance of diabetic dentin [ 9 ]. To our knowledge, no study has directly compared multiple root canal obturation approaches in diabetic dentin under standardized conditions while isolating the intrinsic bonding potential of sealers. Therefore, this study aimed to evaluate the influence of various obturation techniques and sealer types on the push-out bond strength in dentin derived from diabetic patients. The present study was not intended to compare diabetic and healthy dentin. Instead, it focused exclusively on dentin derived from diabetic patients to evaluate the relative performance of different obturation techniques under clinically compromised conditions, allowing assessment of intragroup differences without additional confounding factors. Therefore, this study aimed to compare the push-out bond strength of different root canal obturation approaches using different sealer materials in teeth obtained from patients with diabetes mellitus. A sealer-only group was included to isolate and assess the direct interaction between the sealer and dentin, independent of the influence of the gutta-percha. The null hypothesis (H₀) was that there would be no significant differences in the push-out bond strength among the tested obturation techniques. MATERIALS AND METHODS Sample Selection The required sample size was calculated using GPower software (GPower 3.1.7, Windows, Düsseldorf, Germany) to obtain eight specimens per group. To increase the robustness of the analysis and compensate for potential specimen loss, the final sample size was increased to 10 specimens per group (40 teeth). After obtaining ethical approval from the Firat University Non-Interventional Ethics Committee (Decision no: 2023/10–31), single-rooted mandibular premolar teeth extracted from patients diagnosed with diabetes mellitus (DM) and each possessing a single round canal were collected and examined visually and radiographically. All teeth were extracted for clinical reasons unrelated to the objectives of this study, such as periodontal and orthodontic indications. Teeth with prior root canal treatment, cracks, or caries were excluded from the study. Soft tissues and debris were removed from the collected teeth using a curette. Owing to limitations in patient records, no data were available regarding the type of diabetes or disease duration. Only patients with documented diabetes mellitus and HbA1c levels ≥ 6.5% obtained from their medical records at the time of tooth extraction were included in the study [ 1 ]. To standardize the root lengths, the roots were sectioned under water cooling with a diamond disc to obtain a 12 millimeters (mm) segment from the apex. Canal patency was confirmed using a #15 K-file (Dentsply/Maillefer, Ballaigues, Switzerland). The root canals were then instrumented using the Reciproc system (VDW, Munich, Germany) up to size R40. During the shaping procedure, a total of 10 mL of 2.5% sodium hypochlorite (NaOCl) was used per canal, delivered incrementally using a flexible, side-vented irrigation needle. After instrumentation, the smear layer was removed using 1 mL of 17% ethylenediaminetetraacetic acid (EDTA) for 1 min. Final irrigation was performed with 2 mL of distilled water, and the canals were dried with sterile paper points. Root Canal Obturation Randomization was performed at the tooth level using a simple random allocation method prior to the sectioning. Ten teeth were allocated to each experimental group. Each tooth was assigned to a single group to ensure balanced distribution and to prevent intra-tooth correlation across groups. All obturation procedures were performed by a single, experienced operator using various techniques. •In Group 1, cold lateral compaction was performed using an AH Plus sealer (Dentsply DeTrey GmbH, Konstanz, Germany). •In Group 2, warm vertical compaction was performed using the AH Plus sealer and the Elements Free cordless obturation system (SybronEndo/Kerr Endodontics, Orange, CA, USA). •In Group 3, single-cone obturation was performed using gutta-percha and Bioserra sealer (Meta Biomed, Dongsaeng Myeong 1-ro, Korea). •In Group 4, the root canals were filled exclusively with the Bioserra sealer without the use of gutta-percha to evaluate the intrinsic bonding ability of the sealer to root dentin. To ensure complete setting of the root canal sealers, the specimens were stored at 37°C and 100% humidity for one week. After obturation, standardized slices of 1 mm thickness were obtained from the coronal, middle, and apical thirds (at 2.5, 5, and 8 mm from the apex, respectively) using a water-cooled diamond saw (Isomet, Buehler Ltd., USA). Push-Out Bond Strength Test The 120 slices were subjected to a push-out test using a universal testing machine (Instron Industrial Products, Norwood, MA, USA) at a crosshead speed of 1 mm/min in the apico-coronal direction (Fig. 1 ). Different plungers were used for the coronal, middle, and apical sections to ensure a proper fit within the canal space, avoiding contact with the surrounding dentin. Each specimen was positioned with its apical side facing the plunger to minimize stress on the dentin. The force required to dislodge the filling material (in kilonewtons (kN)) was converted to stress (in megapascals (MPa)) [ 22 ]. The upper and lower diameters of each specimen were measured individually using the following formula: MPa = F / SL, where SL = sealer adhesion area = π(R + r)g, π = 3.14, R = coronal canal radius (mm), r = apical canal radius (mm), and g = slice thickness (mm). Dislodgement of the filling was confirmed by a sudden drop in the load–displacement curve. The push-out bond strength was calculated for each root slice. For statistical analysis, the mean push-out bond strength values obtained from the coronal, middle, and apical slices of each tooth were calculated. Data Analysis Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 23.0 (SPSS Inc., Chicago, IL, USA). For statistical analysis, the mean push-out bond strength value per tooth was considered as the statistical unit. The normality of the data was assessed using the Kolmogorov–Smirnov and Shapiro–Wilk tests, and the homogeneity of variances was verified using Levene’s test. For normally distributed data with equal variances, one-way ANOVA was used to compare the push-out bond strength values, followed by Tukey’s HSD post hoc test for pairwise comparisons. The results are presented as mean ± standard deviation, with a significance level set at p < 0.05. RESULTS No statistically significant differences were observed between the Cold Lateral and Warm Vertical groups in the coronal, middle, or apical thirds (p > 0.05; Table 1 ). In contrast, both the hydraulic single cone and bioceramic sealer-only groups exhibited significantly higher push-out bond strength values in all root regions compared with the conventional techniques (p < 0.001; Table 1 ). A significant difference was also detected between the hydraulic single cone and bioceramic sealer-only groups in the coronal region, with higher values observed in the bioceramic sealer-only group (p < 0.05; Table 1 ). Table 1 Push-out bond strength (MPa) according to obturation technique and root region (mean ± SD). Coronal Middle Apical N Mean Std. Deviation P* N Mean Std. Deviation P* N Mean Std. Deviation P* Cold Lateral 10 3.716 0.678 < 0.001 Cold Lateral 10 4.731 0.545 < 0.001 Cold Lateral 10 4.469 0.746 < 0.001 Warm Vertical 10 3.249 0.701 Warm Vertical 10 5.742 0.889 Warm Vertical 10 5.444 1.016 Hydraulic a1,b1 10 5.086 0.655 Hydraulic a1,b1 10 9.246 0.938 Hydraulic a1,b1 10 8.787 1.097 Bioceramic a2,b2,c 10 9.140 0.985 Bioceramic a,b,c 10 13.123 1.408 Bioceramic a,b,c 10 11.101 1.332 * All groups were analyzed using one-way ANOVA followed by Tukey’s HSD post hoc test. For each root region (coronal, middle, and apical), different lowercase letters (a, b, c) indicate statistically significant differences among obturation techniques (p < 0.05). Numerical superscripts (1, 2) indicate statistically significant differences among root regions within the same obturation technique (p < 0.05). In the intragroup analysis of the bioceramic sealer-only group, bond strength values in the middle and apical thirds were significantly higher than those in the coronal third (p < 0.001). Moreover, a significant difference was observed between the middle and apical thirds (p < 0.001; Table 2 ). A similar pattern was observed in the hydraulic single cone group, with significantly higher values in the middle and apical thirds than in the coronal third (p < 0.001). This trend was also observed in the Warm Vertical and Cold Lateral groups, although with a lower magnitude and statistical significance (p < 0.05; Table 2 ). Table 2 Regional comparison of push-out bond strength (MPa) within each obturation technique (mean ± SD). Cold Lateral Warm Vertical Hydraulic Bioceramic N Mean Std. Deviation P* N Mean Std. Deviation P* N Mean Std. Deviation P* N Mean Std. Deviation P* Coronal 10 3.716 0.678 < 0.001 Coronal 10 3.249 0.701 < 0.001 Coronal 10 5.086 0.655 < 0.001 Coronal 10 9.140 0.985 < 0.001 Middle a1 10 4.731 0.545 Middle a1 10 5.742 0.889 Middle a1 10 9.246 0.938 Middle a1 10 13.123 1.408 Apical a2 10 4.469 0.746 Apical a2 10 5.444 1.016 Apical a2 10 8.787 1.097 Apical a2,b 10 11.101 1.332 *All groups were analyzed using one-way ANOVA followed by Tukey’s HSD post hoc test. Within each obturation technique, different lowercase letters indicate statistically significant differences among root regions. Numerical superscripts indicate statistically significant differences among obturation techniques within the same root region (p < 0.05). When the obturation techniques were compared across all root regions, both the bioceramic sealer-only and hydraulic single cone groups showed significantly higher overall push-out bond strengths than the conventional groups (p < 0.001; Table 3 ). Bioceramic sealer-only group demonstrated the highest overall mean bond strength, followed in descending order by the Hydraulic Single Cone, Warm Vertical, and Cold Lateral groups. Table 3 Overall comparison of push-out bond strength (MPa) among obturation techniques (mean ± SD). N Mean Std. Deviation P* Cold Lateral 10 4.305 0.774 < 0.001 Warm Vertical 10 4.811 1.413 Hydraulic a,b 10 7.706 2.090 Bioceramic a,b,c 10 11.121 2.050 *Statistical analysis was performed using one-way ANOVA followed by Tukey’s HSD post hoc test. Different lowercase letters (a, b, c) indicate statistically significant differences among obturation techniques (p < 0.05). DISCUSSION This study investigated the influence of various root canal obturation techniques and sealer types on the push-out bond strength in dentin derived from diabetic patients. Chronic hyperglycemia in diabetes promotes the accumulation of advanced glycation end-products (AGEs), which can disrupt collagen integrity [ 9 ]. Diabetes has been associated with an increased susceptibility to vertical root fracture [ 23 ], which may indirectly reflect alterations in dentin mechanical behavior. These changes are generally associated with impaired adhesion of resin-based materials, as hybrid layer formation depends on collagen integrity [ 24 , 25 ]. Therefore, AGE-induced alterations in dentin collagen could potentially influence the bonding performance of epoxy resin–based sealers. [ 21 , 26 ]. In contrast, calcium silicate–based bioceramic sealers rely less on collagen-dependent micromechanical retention and more on ionic exchange and biomineralization with the inorganic phase of dentin [ 10 – 12 ]. This difference in the bonding mechanism may explain the superior performance of the bioceramic materials observed in the present study. However, limited data exists regarding how such alterations affect the adhesion of root canal sealers in diabetic dentin [ 13 , 27 ]. Although previous studies have demonstrated the bonding potential of bioceramic sealers to healthy dentin through chemical interactions [ 11 , 28 ], the present study uniquely evaluated their performance in biochemically compromised dentin under clinically relevant conditions. The results demonstrated that both the obturation technique and type of sealer had a significant impact on push-out bond strength. Groups utilizing bioceramic sealers exhibited consistently higher bond strength across all root sections than those utilizing techniques (p < 0.001), suggesting that the chemical bonding capacity and bioactivity of calcium silicate–based materials may offer distinct advantages in diabetic dentin [ 10 ]. In the coronal region, the bioceramic sealer-only group demonstrated significantly higher bond strength than the hydraulic single cone group (p < 0.001; Table 1 ). This difference may be attributed to the more homogeneous sealer mass and greater interface adaptation achieved with the bioceramic technique, which enhances chemical bonding and reduces voids. In support of this, previous studies have shown that calcium silicate–based sealers exhibit superior dentinal tubule penetration and promote biomineralization owing to their hydrophilic and bioactive properties, which reinforce interfacial bonding over time [ 10 , 11 , 29 ]. Within the Bioceramic sealer-only group, the bond strength values in the middle and apical thirds were significantly higher than those in the coronal region (p < 0.001; Table 2 ), which is consistent with previous studies reporting increased push-out bond strength toward the middle and apical root thirds for calcium silicate–based sealers [ 30 , 31 ]. This finding may be related to regional differences in the dentin morphology and canal geometry. Although apical dentin generally presents with narrower dentinal tubules, the reduced canal diameter and increased confinement of the filling material may enhance frictional resistance and sealer adaptation in the apical sections [ 12 ]. Additionally, diabetes-induced alterations in the dentin structure, including changes in collagen integrity and mineral composition associated with AGEs, may influence bonding behavior in a region-dependent manner [ 13 ]. However, these proposed explanations remain hypothetical, as the present study did not directly assess the regional structural or biochemical differences in diabetic dentin. In the hydraulic single cone group, bond strength values in the middle and apical thirds were significantly higher than those in the coronal third (p < 0.05; Table 2 ). Conversely, Cold Lateral and Warm Vertical compaction demonstrated significantly lower bond strengths than bioceramic-based approaches (p < 0.05; Table 3 ). These findings indicate that resin-based sealers may offer limited adhesion to structurally compromised diabetic dentin, likely because they rely on mechanical interlocking rather than chemical bonding [ 32 ]. Bioceramic sealers demonstrated the highest bond strength values in the middle and apical thirds, further confirming their superior adhesion characteristics in root regions with narrower tubules and a higher surface area (p < 0.001; Table 2 ). These results highlight the potential clinical relevance of calcium silicate–based sealers in diabetic dentin, where microstructural and biochemical changes may compromise the effectiveness of conventional obturation systems. Although the standard deviation values did not exceed the mean values, a relatively greater dispersion was observed in certain groups, particularly those involving bioceramic sealers. This variability may reflect the heterogeneity of dentin substrate quality among individuals with diabetes [ 9 , 13 ]. Chronic hyperglycemia does not affect dentin uniformly; variations in disease duration and metabolic history may lead to heterogeneous structural and biochemical alterations [ 9 ]. Such changes can influence the mineral composition, collagen integrity, and biomechanical behavior of dentin [ 13 ], which may partially account for the variability observed in the push-out bond strength measurements in the present study. This study has several limitations that should be considered when interpreting the findings. First, the specimens were collected from diabetic patients of variable ages and disease durations, which may have introduced heterogeneity in dentin structure and mechanical behavior [ 9 , 13 ]. Second, the push-out bond strength test was conducted in vitro, lacking physiological conditions such as masticatory loading, thermal cycling, and salivary interactions, which may affect long-term performance [ 33 ]. Third, only single-rooted canals with standardized anatomy were used, and variations in canal morphology or irrigation protocols were not explored. Finally, although previous studies have included non-diabetic control groups to characterize diabetes-related dentin changes [ 13 , 27 ], the present study focused exclusively on diabetic samples to isolate the effects of the obturation techniques. These limitations warrant caution when generalizing the results to broader clinical scenarios. Despite these limitations, the present study provides valuable insights into the bonding behavior of root canal obturation materials in a clinically relevant diabetic dentin model, addressing a significant gap in the endodontic literature. Future studies should explore the biochemical mechanisms of sealer–dentin interactions in diabetes, including the role of advanced glycation end-products and collagen alterations. The absence of a non-diabetic control group should be considered when interpreting the results, as the primary objective of the present study was not to compare diabetic and non-diabetic dentin but to evaluate the relative performance of different obturation techniques within a diabetic population. Aging protocols that simulate intraoral conditions (e.g., thermocycling and mechanical loading) are also required to assess long-term material performance. Although diabetes was confirmed using HbA1c values of ≥ 6.5%, detailed information regarding diabetes type, disease duration, and long-term metabolic control was not available, which should be considered when interpreting these results. From a clinical standpoint, the interaction between dentin substrate quality and sealer characteristics may be particularly relevant in patients with systemic conditions, such as diabetes. Although the present findings are based on in vitro conditions, the improved bonding performance of bioceramic sealers in diabetic dentin suggests that material selection may play a critical role in endodontic treatment outcomes in medically compromised patients. The findings are specific to diabetic dentin and should not be extrapolated to healthy substrates; however, comparative evaluation of obturation techniques within compromised dentin remains clinically relevant. CONCLUSIONS Within the limitations of this in vitro study, both the obturation technique and the type of sealer significantly influenced bond strength in diabetic dentin. Bioceramic-based obturation exhibited superior adhesion compared to conventional methods, underscoring its potential clinical relevance in the endodontic treatment of diabetic dentin. Abbreviations AGEs Advanced Glycation End–products ANOVA Analysis of Variance DM Diabetes Mellitus EDTA Ethylenediaminetetraacetic Acid GP Gutta–Percha HbA1c Glycated Hemoglobin HSD Honestly Significant Difference IDF International Diabetes Federation kN Kilonewton MPa Megapascal NaOCl Sodium Hypochlorite Declarations Conflict of interest and source of funding statement: The authors declare that they have no conflict of interest. This study was self-funded by the authors. ETHICS APPROVAL AND CONSENT TO PARTICIPATE All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its later amendments. Ethical approval for this study was obtained from the Firat University Non-Interventional Ethics Committee (Decision no: 2023/10–31). Written informed consent was obtained from all participants prior to tooth extraction, allowing the use of extracted teeth for research purposes. All teeth were collected after routine dental extractions performed for clinical reasons unrelated to this study. CONSENT FOR PUBLICATION Not applicable COMPETING INTERESTS The authors declare that they have no conflict of interest. CLINICAL TRIAL NUMBER Not applicable FUNDING There is no funding. Author Contribution Mevlüt Sinan OCAK: Methodology, investigation, data curation, writing – original draft, writing – review & editing.Mehmet ESKİBAĞLAR: Supervision, methodology, resources, investigation, funding acquisition, resources, writing – review & editing.Mustafa GÜNDOĞAR: Conceptualization, methodology, investigation, writing – review & editing. ACKNOWLEDGEMENTS None. Data Availability All data generated or analyzed during this study are included in this published article. 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Araujo VLC, Cruvinel PB, Palma-Dibb RG, Gariba-Silva R. In vitro bond strength of an epoxy resin-based root canal sealer to root dentin irradiated with high-power lasers and adhesive interface analyses. Lasers Med Sci. 2018;33(2):271–7. Chen WP, Chen YY, Huang SH, Lin CP. Limitations of push-out test in bond strength measurement. J Endod. 2013;39(2):283–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8960277\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":597819495,\"identity\":\"94471467-d2a7-4adb-beb3-950ef881640c\",\"order_by\":0,\"name\":\"Mevlüt Sinan OCAK\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYNCCAzb8bBAWM9Fa0iTbGBgYG8Ba2IjTcliygWgtuv2HD374cea8BJ/04ecPGCqsExvkex/g1WJ2Iy1ZsufGbQk2vjTDBoYz6YkNbOwGBLTwmDHwfLhdx8bDYNjA2HYYqIWAy8zOnzFj/PPhnAQbD/vHBsZ/xGg5kGPGzHPjAFALD9CWBmK0AP0iLXMmGaSlcEbCsXTjNrY0Qg47fPDjm2N2EvI97Bs+fKixlu1nPoZfCypIYCA2JkfBKBgFo2AU4AUAGZpCCG8sySMAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Fırat University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Mevlüt\",\"middleName\":\"Sinan\",\"lastName\":\"OCAK\",\"suffix\":\"\"},{\"id\":597819497,\"identity\":\"7d2e994f-45c6-40e5-8a95-dbf9fbe4d274\",\"order_by\":1,\"name\":\"Mehmet ESKİBAĞLAR\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Fırat University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mehmet\",\"middleName\":\"\",\"lastName\":\"ESKİBAĞLAR\",\"suffix\":\"\"},{\"id\":597819499,\"identity\":\"889916dd-ba82-4fdc-afab-7dbf534d22cc\",\"order_by\":2,\"name\":\"Mustafa GÜNDOĞAR\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Istanbul Medipol University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mustafa\",\"middleName\":\"\",\"lastName\":\"GÜNDOĞAR\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-02-24 18:23:55\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8960277/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8960277/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":104175003,\"identity\":\"f46a18cc-7ad9-4df7-8a94-d859f6c0c55e\",\"added_by\":\"auto\",\"created_at\":\"2026-03-08 16:24:35\",\"extension\":\"jpeg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":403270,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSample preparation and push-out testing of root slices after obturation with different techniques and materials.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8960277/v1/ec35ebc21b1a1e5fdd5d1f05.jpeg\"},{\"id\":104876833,\"identity\":\"4fe37a15-6e13-4b4e-bfc1-277e92ca1686\",\"added_by\":\"auto\",\"created_at\":\"2026-03-18 08:43:49\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":960374,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8960277/v1/61554877-5715-40e0-b2db-62178217f75e.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Comparative Evaluation of Root Canal Obturation Techniques and Sealers in Diabetic Dentin: An in-vitro Push-Out Bond Strength Test\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eDiabetes mellitus (DM) is a complex multisystemic metabolic disorder projected to affect nearly 853\\u0026nbsp;million people by 2050. Currently, more than 589\\u0026nbsp;million adults aged 20\\u0026ndash;79 years live with DM worldwide, reflecting a significant global health burden [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. DM is characterized by persistent hyperglycemia and arises from a combination of genetic and environmental factors [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. It exerts systemic effects on multiple organs and tissues, including the oral cavity [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Previous studies have shown that poor glycemic control can negatively affect the dental pulp, connective tissues, and cellular structures, thereby compromising oral health [\\u003cspan additionalcitationids=\\\"CR5\\\" citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Dentin, a mineralized tissue composed of approximately 70% inorganic material, 20% organic matrix, and 10% water, is highly relevant for endodontic treatment [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. DM alters the trace element composition of dentin\\u0026mdash;particularly strontium, magnesium, zinc, and selenium\\u0026mdash;within the hydroxyapatite structure. These changes may affect the crystallinity and physicochemical characteristics of the mineral phase, potentially weakening the biomechanical properties of dentin, reducing microhardness, lowering fracture resistance, and impairing adhesion capacity of root canal filling materials [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eGiven these substrate alterations, the interaction between dentin and obturation materials may be material-dependent. Calcium silicate\\u0026ndash;based bioceramic sealers release calcium ions and promote biomineralization at the sealer\\u0026ndash;dentin interface, resulting in the formation of hydroxyapatite-like interfacial structures and chemical interactions with the inorganic phase of dentin [\\u003cspan additionalcitationids=\\\"CR11\\\" citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Therefore, in mineral-altered diabetic dentin, it may be hypothesized that bioceramic sealers may establish enhanced substrate interactions through ionic exchange and interfacial mineral deposition compared with epoxy resin\\u0026ndash;based sealers, which rely predominantly on micromechanical retention and limited chemical bonding [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. This potential difference in the bonding mechanism may be particularly relevant in structurally compromised dentin affected by chronic hyperglycemia [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eRoot canal obturation aims to achieve a fluid-tight seal along the root canal system, commonly using gutta-percha (GP) in combination with a sealer. Traditional techniques, such as cold lateral compaction, are still widely used but have limitations, including insufficient adaptation to canal walls and potential root fractures due to microcrack formation. Warm vertical compaction improves adaptation but remains technique sensitive [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. In contrast, newly developed calcium silicate\\u0026ndash;based bioceramic sealers, such as Bioserra, which is a premixed sealer containing tricalcium silicate and dicalcium silicate as bioactive components, together with calcium aluminate, calcium aluminum oxide, tricalcium aluminate, and tantalum as radiopacifiers, have demonstrated superior push-out bond strength compared to resin-based sealers in healthy dentin [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e]. However, their performance in structurally compromised diabetic dentin is unclear.\\u003c/p\\u003e \\u003cp\\u003eOne of the main objectives of root canal obturation is to reinforce the root dentin and increase its resistance to fracture [\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]. It has been suggested that materials that adhere to the dentin surface can contribute to strengthening the remaining tooth structure [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. The push-out bond strength test is widely used to evaluate the adhesion between obturation materials and canal walls because of its simplicity and reproducibility [\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]. This test reflects a combination of frictional forces, molecular interactions, and chemical bonding between the materials and dentinal walls [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eA review of the available literature indicates that, although several studies have assessed the bonding ability of individual materials, such as mineral trioxide aggregate (MTA) or specific sealers, in diabetic dentin [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e], limited evidence exists regarding how different obturation techniques influence bond strength in this altered substrate. Most previous investigations have focused primarily on material properties rather than on technique-dependent variables. Furthermore, the current literature highlights the limited and heterogeneous nature of data concerning the mechanical performance of diabetic dentin [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. To our knowledge, no study has directly compared multiple root canal obturation approaches in diabetic dentin under standardized conditions while isolating the intrinsic bonding potential of sealers. Therefore, this study aimed to evaluate the influence of various obturation techniques and sealer types on the push-out bond strength in dentin derived from diabetic patients. The present study was not intended to compare diabetic and healthy dentin. Instead, it focused exclusively on dentin derived from diabetic patients to evaluate the relative performance of different obturation techniques under clinically compromised conditions, allowing assessment of intragroup differences without additional confounding factors.\\u003c/p\\u003e \\u003cp\\u003eTherefore, this study aimed to compare the push-out bond strength of different root canal obturation approaches using different sealer materials in teeth obtained from patients with diabetes mellitus. A sealer-only group was included to isolate and assess the direct interaction between the sealer and dentin, independent of the influence of the gutta-percha. The null hypothesis (H₀) was that there would be no significant differences in the push-out bond strength among the tested obturation techniques.\\u003c/p\\u003e\"},{\"header\":\"MATERIALS AND METHODS\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSample Selection\\u003c/h2\\u003e \\u003cp\\u003e\\u003cdiv class=\\\"BlockQuote\\\"\\u003e\\u003cp\\u003eThe required sample size was calculated using GPower software (GPower 3.1.7, Windows, D\\u0026uuml;sseldorf, Germany) to obtain eight specimens per group. To increase the robustness of the analysis and compensate for potential specimen loss, the final sample size was increased to 10 specimens per group (40 teeth).\\u003c/p\\u003e\\u003cp\\u003e After obtaining ethical approval from the Firat University Non-Interventional Ethics Committee (Decision no: 2023/10\\u0026ndash;31), single-rooted mandibular premolar teeth extracted from patients diagnosed with diabetes mellitus (DM) and each possessing a single round canal were collected and examined visually and radiographically. All teeth were extracted for clinical reasons unrelated to the objectives of this study, such as periodontal and orthodontic indications. Teeth with prior root canal treatment, cracks, or caries were excluded from the study. Soft tissues and debris were removed from the collected teeth using a curette. Owing to limitations in patient records, no data were available regarding the type of diabetes or disease duration. Only patients with documented diabetes mellitus and HbA1c levels\\u0026thinsp;\\u0026ge;\\u0026thinsp;6.5% obtained from their medical records at the time of tooth extraction were included in the study [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e].\\u003c/p\\u003e\\u003cp\\u003eTo standardize the root lengths, the roots were sectioned under water cooling with a diamond disc to obtain a 12 millimeters (mm) segment from the apex. Canal patency was confirmed using a #15 K-file (Dentsply/Maillefer, Ballaigues, Switzerland). The root canals were then instrumented using the Reciproc system (VDW, Munich, Germany) up to size R40. During the shaping procedure, a total of 10 mL of 2.5% sodium hypochlorite (NaOCl) was used per canal, delivered incrementally using a flexible, side-vented irrigation needle. After instrumentation, the smear layer was removed using 1 mL of 17% ethylenediaminetetraacetic acid (EDTA) for 1 min. Final irrigation was performed with 2 mL of distilled water, and the canals were dried with sterile paper points.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eRoot Canal Obturation\\u003c/h3\\u003e\\n\\u003cp\\u003eRandomization was performed at the tooth level using a simple random allocation method prior to the sectioning. Ten teeth were allocated to each experimental group. Each tooth was assigned to a single group to ensure balanced distribution and to prevent intra-tooth correlation across groups. All obturation procedures were performed by a single, experienced operator using various techniques.\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e\\u0026bull;In Group 1, cold lateral compaction was performed using an AH Plus sealer (Dentsply DeTrey GmbH, Konstanz, Germany).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e\\u0026bull;In Group 2, warm vertical compaction was performed using the AH Plus sealer and the Elements Free cordless obturation system (SybronEndo/Kerr Endodontics, Orange, CA, USA).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e\\u0026bull;In Group 3, single-cone obturation was performed using gutta-percha and Bioserra sealer (Meta Biomed, Dongsaeng Myeong 1-ro, Korea).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e\\u0026bull;In Group 4, the root canals were filled exclusively with the Bioserra sealer without the use of gutta-percha to evaluate the intrinsic bonding ability of the sealer to root dentin.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eTo ensure complete setting of the root canal sealers, the specimens were stored at 37\\u0026deg;C and 100% humidity for one week. After obturation, standardized slices of 1 mm thickness were obtained from the coronal, middle, and apical thirds (at 2.5, 5, and 8 mm from the apex, respectively) using a water-cooled diamond saw (Isomet, Buehler Ltd., USA).\\u003c/p\\u003e\\n\\u003ch3\\u003ePush-Out Bond Strength Test\\u003c/h3\\u003e\\n\\u003cp\\u003eThe 120 slices were subjected to a push-out test using a universal testing machine (Instron Industrial Products, Norwood, MA, USA) at a crosshead speed of 1 mm/min in the apico-coronal direction (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Different plungers were used for the coronal, middle, and apical sections to ensure a proper fit within the canal space, avoiding contact with the surrounding dentin. Each specimen was positioned with its apical side facing the plunger to minimize stress on the dentin.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe force required to dislodge the filling material (in kilonewtons (kN)) was converted to stress (in megapascals (MPa)) [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. The upper and lower diameters of each specimen were measured individually using the following formula:\\u003c/p\\u003e \\u003cp\\u003eMPa\\u0026thinsp;=\\u0026thinsp;F / SL,\\u003c/p\\u003e \\u003cp\\u003ewhere SL\\u0026thinsp;=\\u0026thinsp;sealer adhesion area\\u0026thinsp;=\\u0026thinsp;π(R\\u0026thinsp;+\\u0026thinsp;r)g,\\u003c/p\\u003e \\u003cp\\u003eπ\\u0026thinsp;=\\u0026thinsp;3.14, R\\u0026thinsp;=\\u0026thinsp;coronal canal radius (mm), r\\u0026thinsp;=\\u0026thinsp;apical canal radius (mm), and g\\u0026thinsp;=\\u0026thinsp;slice thickness (mm).\\u003c/p\\u003e \\u003cp\\u003eDislodgement of the filling was confirmed by a sudden drop in the load\\u0026ndash;displacement curve. The push-out bond strength was calculated for each root slice. For statistical analysis, the mean push-out bond strength values obtained from the coronal, middle, and apical slices of each tooth were calculated.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData Analysis\\u003c/h2\\u003e \\u003cp\\u003eStatistical analyses were performed using IBM SPSS Statistics for Windows, Version 23.0 (SPSS Inc., Chicago, IL, USA). For statistical analysis, the mean push-out bond strength value per tooth was considered as the statistical unit. The normality of the data was assessed using the Kolmogorov\\u0026ndash;Smirnov and Shapiro\\u0026ndash;Wilk tests, and the homogeneity of variances was verified using Levene\\u0026rsquo;s test. For normally distributed data with equal variances, one-way ANOVA was used to compare the push-out bond strength values, followed by Tukey\\u0026rsquo;s HSD post hoc test for pairwise comparisons. The results are presented as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;standard deviation, with a significance level set at p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eNo statistically significant differences were observed between the Cold Lateral and Warm Vertical groups in the coronal, middle, or apical thirds (p\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.05; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). In contrast, both the hydraulic single cone and bioceramic sealer-only groups exhibited significantly higher push-out bond strength values in all root regions compared with the conventional techniques (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). A significant difference was also detected between the hydraulic single cone and bioceramic sealer-only groups in the coronal region, with higher values observed in the bioceramic sealer-only group (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003ePush-out bond strength (MPa) according to obturation technique and root region (mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD).\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"15\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c9\\\" colnum=\\\"9\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c10\\\" colnum=\\\"10\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c11\\\" colnum=\\\"11\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c12\\\" colnum=\\\"12\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c13\\\" colnum=\\\"13\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c14\\\" colnum=\\\"14\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c15\\\" colnum=\\\"15\\\"\\u003e\\u003c/div\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c5\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eCoronal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c10\\\" namest=\\\"c6\\\"\\u003e \\u003cp\\u003eMiddle\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c15\\\" namest=\\\"c11\\\"\\u003e \\u003cp\\u003eApical\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eStd. Deviation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eP*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003eMean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003eStd. Deviation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003eP*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003eN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e \\u003cp\\u003eMean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c14\\\"\\u003e \\u003cp\\u003eStd. Deviation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c15\\\"\\u003e \\u003cp\\u003eP*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCold Lateral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.716\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.678\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eCold Lateral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e4.731\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e0.545\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eCold Lateral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e \\u003cp\\u003e4.469\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c14\\\"\\u003e \\u003cp\\u003e0.746\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c15\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWarm Vertical\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.249\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.701\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eWarm Vertical\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e5.742\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e0.889\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eWarm Vertical\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e \\u003cp\\u003e5.444\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c14\\\"\\u003e \\u003cp\\u003e1.016\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHydraulic \\u003csup\\u003ea1,b1\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5.086\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.655\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eHydraulic \\u003csup\\u003ea1,b1\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e9.246\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e0.938\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eHydraulic \\u003csup\\u003ea1,b1\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e \\u003cp\\u003e8.787\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c14\\\"\\u003e \\u003cp\\u003e1.097\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBioceramic \\u003csup\\u003ea2,b2,c\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9.140\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.985\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eBioceramic \\u003csup\\u003ea,b,c\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e13.123\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e1.408\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eBioceramic \\u003csup\\u003ea,b,c\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e \\u003cp\\u003e11.101\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c14\\\"\\u003e \\u003cp\\u003e1.332\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"15\\\"\\u003e* All groups were analyzed using one-way ANOVA followed by Tukey\\u0026rsquo;s HSD post hoc test. For each root region (coronal, middle, and apical), different lowercase letters (a, b, c) indicate statistically significant differences among obturation techniques (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). Numerical superscripts (1, 2) indicate statistically significant differences among root regions within the same obturation technique (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05).\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn the intragroup analysis of the bioceramic sealer-only group, bond strength values in the middle and apical thirds were significantly higher than those in the coronal third (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Moreover, a significant difference was observed between the middle and apical thirds (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). A similar pattern was observed in the hydraulic single cone group, with significantly higher values in the middle and apical thirds than in the coronal third (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). This trend was also observed in the Warm Vertical and Cold Lateral groups, although with a lower magnitude and statistical significance (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eRegional comparison of push-out bond strength (MPa) within each obturation technique (mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD).\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"20\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c9\\\" colnum=\\\"9\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c10\\\" colnum=\\\"10\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c11\\\" colnum=\\\"11\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c12\\\" colnum=\\\"12\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c13\\\" colnum=\\\"13\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c14\\\" colnum=\\\"14\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c15\\\" colnum=\\\"15\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c16\\\" colnum=\\\"16\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c17\\\" colnum=\\\"17\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c18\\\" colnum=\\\"18\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c19\\\" colnum=\\\"19\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c20\\\" colnum=\\\"20\\\"\\u003e\\u003c/div\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c5\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eCold Lateral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c10\\\" namest=\\\"c6\\\"\\u003e \\u003cp\\u003eWarm Vertical\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c15\\\" namest=\\\"c11\\\"\\u003e \\u003cp\\u003eHydraulic\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"5\\\" nameend=\\\"c20\\\" namest=\\\"c16\\\"\\u003e \\u003cp\\u003eBioceramic\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eStd. Deviation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eP*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003eMean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003eStd. Deviation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\"\\u003e \\u003cp\\u003eP*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003eN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e \\u003cp\\u003eMean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c14\\\"\\u003e \\u003cp\\u003eStd. Deviation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c15\\\"\\u003e \\u003cp\\u003eP*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c16\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c17\\\"\\u003e \\u003cp\\u003eN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c18\\\"\\u003e \\u003cp\\u003eMean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c19\\\"\\u003e \\u003cp\\u003eStd. Deviation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c20\\\"\\u003e \\u003cp\\u003eP*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCoronal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3.716\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.678\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eCoronal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e3.249\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e0.701\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c10\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eCoronal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e \\u003cp\\u003e5.086\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c14\\\"\\u003e \\u003cp\\u003e0.655\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c15\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c16\\\"\\u003e \\u003cp\\u003eCoronal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c17\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c18\\\"\\u003e \\u003cp\\u003e9.140\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c19\\\"\\u003e \\u003cp\\u003e0.985\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c20\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMiddle \\u003csup\\u003ea1\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.731\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.545\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMiddle \\u003csup\\u003ea1\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e5.742\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e0.889\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eMiddle \\u003csup\\u003ea1\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e \\u003cp\\u003e9.246\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c14\\\"\\u003e \\u003cp\\u003e0.938\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c16\\\"\\u003e \\u003cp\\u003eMiddle \\u003csup\\u003ea1\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c17\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c18\\\"\\u003e \\u003cp\\u003e13.123\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c19\\\"\\u003e \\u003cp\\u003e1.408\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eApical \\u003csup\\u003ea2\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.469\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.746\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eApical \\u003csup\\u003ea2\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e \\u003cp\\u003e5.444\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c9\\\"\\u003e \\u003cp\\u003e1.016\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c11\\\"\\u003e \\u003cp\\u003eApical \\u003csup\\u003ea2\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c12\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c13\\\"\\u003e \\u003cp\\u003e8.787\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c14\\\"\\u003e \\u003cp\\u003e1.097\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c16\\\"\\u003e \\u003cp\\u003eApical \\u003csup\\u003ea2,b\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c17\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c18\\\"\\u003e \\u003cp\\u003e11.101\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c19\\\"\\u003e \\u003cp\\u003e1.332\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"20\\\"\\u003e*All groups were analyzed using one-way ANOVA followed by Tukey\\u0026rsquo;s HSD post hoc test. Within each obturation technique, different lowercase letters indicate statistically significant differences among root regions. Numerical superscripts indicate statistically significant differences among obturation techniques within the same root region (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05).\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eWhen the obturation techniques were compared across all root regions, both the bioceramic sealer-only and hydraulic single cone groups showed significantly higher overall push-out bond strengths than the conventional groups (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). Bioceramic sealer-only group demonstrated the highest overall mean bond strength, followed in descending order by the Hydraulic Single Cone, Warm Vertical, and Cold Lateral groups.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eOverall comparison of push-out bond strength (MPa) among obturation techniques (mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD).\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eN\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMean\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eStd. Deviation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eP*\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCold Lateral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.305\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.774\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWarm Vertical\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4.811\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1.413\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHydraulic \\u003csup\\u003ea,b\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.706\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2.090\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBioceramic \\u003csup\\u003ea,b,c\\u003c/sup\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11.121\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2.050\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"5\\\"\\u003e*Statistical analysis was performed using one-way ANOVA followed by Tukey\\u0026rsquo;s HSD post hoc test. Different lowercase letters (a, b, c) indicate statistically significant differences among obturation techniques (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05).\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eThis study investigated the influence of various root canal obturation techniques and sealer types on the push-out bond strength in dentin derived from diabetic patients. Chronic hyperglycemia in diabetes promotes the accumulation of advanced glycation end-products (AGEs), which can disrupt collagen integrity [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Diabetes has been associated with an increased susceptibility to vertical root fracture [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e], which may indirectly reflect alterations in dentin mechanical behavior. These changes are generally associated with impaired adhesion of resin-based materials, as hybrid layer formation depends on collagen integrity [\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e]. Therefore, AGE-induced alterations in dentin collagen could potentially influence the bonding performance of epoxy resin\\u0026ndash;based sealers. [\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e]. In contrast, calcium silicate\\u0026ndash;based bioceramic sealers rely less on collagen-dependent micromechanical retention and more on ionic exchange and biomineralization with the inorganic phase of dentin [\\u003cspan additionalcitationids=\\\"CR11\\\" citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. This difference in the bonding mechanism may explain the superior performance of the bioceramic materials observed in the present study. However, limited data exists regarding how such alterations affect the adhesion of root canal sealers in diabetic dentin [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e]. Although previous studies have demonstrated the bonding potential of bioceramic sealers to healthy dentin through chemical interactions [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e], the present study uniquely evaluated their performance in biochemically compromised dentin under clinically relevant conditions.\\u003c/p\\u003e \\u003cp\\u003eThe results demonstrated that both the obturation technique and type of sealer had a significant impact on push-out bond strength. Groups utilizing bioceramic sealers exhibited consistently higher bond strength across all root sections than those utilizing techniques (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), suggesting that the chemical bonding capacity and bioactivity of calcium silicate\\u0026ndash;based materials may offer distinct advantages in diabetic dentin [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn the coronal region, the bioceramic sealer-only group demonstrated significantly higher bond strength than the hydraulic single cone group (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). This difference may be attributed to the more homogeneous sealer mass and greater interface adaptation achieved with the bioceramic technique, which enhances chemical bonding and reduces voids. In support of this, previous studies have shown that calcium silicate\\u0026ndash;based sealers exhibit superior dentinal tubule penetration and promote biomineralization owing to their hydrophilic and bioactive properties, which reinforce interfacial bonding over time [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eWithin the Bioceramic sealer-only group, the bond strength values in the middle and apical thirds were significantly higher than those in the coronal region (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e), which is consistent with previous studies reporting increased push-out bond strength toward the middle and apical root thirds for calcium silicate\\u0026ndash;based sealers [\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e]. This finding may be related to regional differences in the dentin morphology and canal geometry. Although apical dentin generally presents with narrower dentinal tubules, the reduced canal diameter and increased confinement of the filling material may enhance frictional resistance and sealer adaptation in the apical sections [\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Additionally, diabetes-induced alterations in the dentin structure, including changes in collagen integrity and mineral composition associated with AGEs, may influence bonding behavior in a region-dependent manner [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. However, these proposed explanations remain hypothetical, as the present study did not directly assess the regional structural or biochemical differences in diabetic dentin.\\u003c/p\\u003e \\u003cp\\u003eIn the hydraulic single cone group, bond strength values in the middle and apical thirds were significantly higher than those in the coronal third (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Conversely, Cold Lateral and Warm Vertical compaction demonstrated significantly lower bond strengths than bioceramic-based approaches (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). These findings indicate that resin-based sealers may offer limited adhesion to structurally compromised diabetic dentin, likely because they rely on mechanical interlocking rather than chemical bonding [\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eBioceramic sealers demonstrated the highest bond strength values in the middle and apical thirds, further confirming their superior adhesion characteristics in root regions with narrower tubules and a higher surface area (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). These results highlight the potential clinical relevance of calcium silicate\\u0026ndash;based sealers in diabetic dentin, where microstructural and biochemical changes may compromise the effectiveness of conventional obturation systems.\\u003c/p\\u003e \\u003cp\\u003eAlthough the standard deviation values did not exceed the mean values, a relatively greater dispersion was observed in certain groups, particularly those involving bioceramic sealers. This variability may reflect the heterogeneity of dentin substrate quality among individuals with diabetes [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Chronic hyperglycemia does not affect dentin uniformly; variations in disease duration and metabolic history may lead to heterogeneous structural and biochemical alterations [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. Such changes can influence the mineral composition, collagen integrity, and biomechanical behavior of dentin [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e], which may partially account for the variability observed in the push-out bond strength measurements in the present study.\\u003c/p\\u003e \\u003cp\\u003eThis study has several limitations that should be considered when interpreting the findings. First, the specimens were collected from diabetic patients of variable ages and disease durations, which may have introduced heterogeneity in dentin structure and mechanical behavior [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. Second, the push-out bond strength test was conducted in vitro, lacking physiological conditions such as masticatory loading, thermal cycling, and salivary interactions, which may affect long-term performance [\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e]. Third, only single-rooted canals with standardized anatomy were used, and variations in canal morphology or irrigation protocols were not explored. Finally, although previous studies have included non-diabetic control groups to characterize diabetes-related dentin changes [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e], the present study focused exclusively on diabetic samples to isolate the effects of the obturation techniques. These limitations warrant caution when generalizing the results to broader clinical scenarios.\\u003c/p\\u003e \\u003cp\\u003eDespite these limitations, the present study provides valuable insights into the bonding behavior of root canal obturation materials in a clinically relevant diabetic dentin model, addressing a significant gap in the endodontic literature. Future studies should explore the biochemical mechanisms of sealer\\u0026ndash;dentin interactions in diabetes, including the role of advanced glycation end-products and collagen alterations. The absence of a non-diabetic control group should be considered when interpreting the results, as the primary objective of the present study was not to compare diabetic and non-diabetic dentin but to evaluate the relative performance of different obturation techniques within a diabetic population. Aging protocols that simulate intraoral conditions (e.g., thermocycling and mechanical loading) are also required to assess long-term material performance. Although diabetes was confirmed using HbA1c values of \\u0026ge;\\u0026thinsp;6.5%, detailed information regarding diabetes type, disease duration, and long-term metabolic control was not available, which should be considered when interpreting these results.\\u003c/p\\u003e \\u003cp\\u003eFrom a clinical standpoint, the interaction between dentin substrate quality and sealer characteristics may be particularly relevant in patients with systemic conditions, such as diabetes. Although the present findings are based on in vitro conditions, the improved bonding performance of bioceramic sealers in diabetic dentin suggests that material selection may play a critical role in endodontic treatment outcomes in medically compromised patients. The findings are specific to diabetic dentin and should not be extrapolated to healthy substrates; however, comparative evaluation of obturation techniques within compromised dentin remains clinically relevant.\\u003c/p\\u003e\"},{\"header\":\"CONCLUSIONS\",\"content\":\"\\u003cp\\u003eWithin the limitations of this in vitro study, both the obturation technique and the type of sealer significantly influenced bond strength in diabetic dentin. Bioceramic-based obturation exhibited superior adhesion compared to conventional methods, underscoring its potential clinical relevance in the endodontic treatment of diabetic dentin.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eAGEs\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eAdvanced Glycation End\\u0026ndash;products\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eANOVA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eAnalysis of Variance\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eDM\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eDiabetes Mellitus\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eEDTA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eEthylenediaminetetraacetic Acid\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eGP\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eGutta\\u0026ndash;Percha\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eHbA1c\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eGlycated Hemoglobin\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eHSD\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eHonestly Significant Difference\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eIDF\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eInternational Diabetes Federation\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ekN\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eKilonewton\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMPa\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eMegapascal\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eNaOCl\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eSodium Hypochlorite\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eConflict of interest and source of funding statement:\\u003c/strong\\u003e The authors declare that they have no conflict of interest. This study was self-funded by the authors.\\u003c/p\\u003e\\n\\u003ch2\\u003eETHICS APPROVAL AND CONSENT TO PARTICIPATE\\u003c/h2\\u003e\\n\\u003cp\\u003eAll procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its later amendments. Ethical approval for this study was obtained from the Firat University Non-Interventional Ethics Committee (Decision no: 2023/10\\u0026ndash;31). Written informed consent was obtained from all participants prior to tooth extraction, allowing the use of extracted teeth for research purposes. All teeth were collected after routine dental extractions performed for clinical reasons unrelated to this study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCONSENT FOR PUBLICATION\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003ch2\\u003eCOMPETING INTERESTS\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors declare that they have no conflict of interest.\\u003c/p\\u003e\\n\\u003ch2\\u003eCLINICAL TRIAL NUMBER\\u003c/h2\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003ch2\\u003eFUNDING\\u003c/h2\\u003e\\n\\u003cp\\u003eThere is no funding.\\u003c/p\\u003e\\n\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\n\\u003cp\\u003eMevl\\u0026uuml;t Sinan OCAK: Methodology, investigation, data curation, writing \\u0026ndash; original draft, writing \\u0026ndash; review \\u0026amp; editing.Mehmet ESKİBAĞLAR: Supervision, methodology, resources, investigation, funding acquisition, resources, writing \\u0026ndash; review \\u0026amp; editing.Mustafa G\\u0026Uuml;NDOĞAR: Conceptualization, methodology, investigation, writing \\u0026ndash; review \\u0026amp; editing.\\u003c/p\\u003e\\n\\u003ch2\\u003eACKNOWLEDGEMENTS\\u003c/h2\\u003e\\n\\u003cp\\u003eNone.\\u003c/p\\u003e\\n\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\n\\u003cp\\u003eAll data generated or analyzed during this study are included in this published article.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eInternational Diabetes Federation: IDF Diabetes Atlas. 2025. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://diabetesatlas.org/resources/idf-diabetes-atlas-2025\\u003c/span\\u003e\\u003cspan address=\\\"https://diabetesatlas.org/resources/idf-diabetes-atlas-2025\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. Accessed: 10 Jul 2025.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTierney L, McPhee S, Papadakis M. Current Medical Diagnosis and Treatment. International ed. New York, NY, USA: Lange Medical Books/McGraw-Hill; 2002.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGraves DT, Liu R, Oates TW. Diabetes-enhanced inflammation and apoptosis: impact on periodontal pathosis. Periodontol 2000. 2007;45:128\\u0026ndash;37.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBender IB, Bender AB. Diabetes mellitus and the dental pulp. J Endod. 2003;29(6):383\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCatanzaro O, Dziubecki D, Lauria LC, Ceron CM, Rodriguez RR. Diabetes and its effects on dental pulp. J Oral Sci. 2006;48(4):195\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLima SM, Grisi DC, Kogawa EM, Franco OL, Peixoto VC, Gon\\u0026ccedil;alves-J\\u0026uacute;nior JF, Arruda MP, et al. Diabetes mellitus and inflammatory pulpal and periapical disease: a review. Int Endod J. 2013;46(8):700\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGoldberg M, Kulkarni AB, Young M, Boskey A. Dentin: structure, composition and mineralization. Front Biosci (Elite Ed). 2011;3(2):711\\u0026ndash;35.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSaghiri MA, Vakhnovetsky J, Samadi E, Napoli S, Samadi F, Conte M, et al. Effects of Diabetes on Elemental Levels and Nanostructure of Root Canal Dentin. J Endod. 2023;49(9):1169\\u0026ndash;75.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHwang KC, Choi JJE, Hussaini HM, Cooper PR, Friedlander LT. Effect of diabetes and hyperglycaemia on the physical and mechanical properties of dentine: a systematic review. Clin Oral Investig. 2025;29(1):55.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eShieh K, Yang J, Zhu EH, Peters OA, Hosseinpour S. Dentinal Tubule Penetrability and Bond Strength of Two Novel Calcium Silicate-Based Root Canal Sealers. Mater (Basel). 2023;16(9):3309.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRadulica N, Sanz JL, Lozano A. Dentin Bond Strength of Calcium Silicate-Based Materials: A Systematic Review of In Vitro Studies. Appl Sci. 2024;14(1):104.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChisnoiu RM, Moldovan M, Prodan D, Chisnoiu AM, Hrab D, Delean AG, et al. In-Vitro Comparative Adhesion Evaluation of Bioceramic and Dual-Cure Resin Endodontic Sealers Using SEM, AFM, Push-Out and FTIR. Appl Sci. 2021;11(10):4454.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSaghiri MA, Karamifar K, Fakharzadeh A, Conte M, Morgano SM. Effect of Diabetes on Tubular Density and Push-out Bond Strength of Mineral Trioxide Aggregate to Dentin. J Endod. 2020;46(11):1584\\u0026ndash;91.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEvans JT, Simon JH. Evaluation of the apical seal produced by injected thermoplasticized Gutta-percha in the absence of smear layer and root canal sealer. J Endod. 1986;12(3):100\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eShemesh H, Wesselink PR, Wu MK. Incidence of dentinal defects after root canal filling procedures. Int Endod J. 2010;43(11):995\\u0026ndash;1000.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFundaoğlu K\\u0026uuml;\\u0026ccedil;\\u0026uuml;kekenci F. The effect of different acidic irrigation solutions on the pushout bond strength of root canal filling. J Dent Res Dent Clin Dent Prospects. 2023;17(1):18\\u0026ndash;22.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eUlusoy OI, Gen\\u0026ccedil; O, Arslan S, Ala\\u0026ccedil;am T, G\\u0026ouml;rg\\u0026uuml;l G. Fracture resistance of roots obturated with three different materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104(5):705\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJohnson ME, Stewart GP, Nielsen CJ, Hatton JF. Evaluation of root reinforcement of endodontically treated teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(3):360\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWang JS, Bai W, Wang Y, Liang YH. Effect of different dentin moisture on the push-out strength of bioceramic root canal sealer. J Dent Sci. 2023;18(1):129\\u0026ndash;34.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBohn S, Ilie N. Wetting behaviour of silicone- and resin-based root canal sealers. Int Endod J. 2014;47(6):542\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOncu A, Ozgur E, Efeoglu S, Celikten B. Evaluation of the effects of diabetes on tooth radiodensity, bond strength of root canal sealers to dentin, and interfacial elemental distribution. BMC Oral Health. 2025;25(1):1780.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCosta JA, Rached-J\\u0026uacute;nior FA, Souza-Gabriel AE, Silva-Sousa YT, Sousa-Neto MD. Push-out strength of methacrylate resin-based sealers to root canal walls. Int Endod J. 2010;43(8):698\\u0026ndash;706.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePradeepKumar AR, JothiLatha S, Durvasulu A, Muralidhar L, Vimalesh Alagu J, Shereen J, et al. Impact of Type 2 Diabetes Mellitus on the Occurrence of Vertical Root Fracture: A Case Control Study. J Endod. 2024;50(4):450\\u0026ndash;e4551.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDelgado HS, Belmar Da Costa A, Polido M, Mano Azul MC, Sauro A. Collagen-depletion strategies in dentin as alternatives to the hybrid layer concept and their effect on bond strength: a systematic review. Sci Rep. 2022;12(1):13028.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBreschi L, Maravic T, Cunha SR, Comba A, Cadenaro M, Tj\\u0026auml;derhane L, et al. Dentin bonding systems: From dentin collagen structure to bond preservation and clinical applications. Dent Mater. 2018;34(1):78\\u0026ndash;96.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMiura J, Nishikawa K, Kubo M, Fukushima S, Hashimoto M, Takeshige F, et al. Accumulation of advanced glycation end-products in human dentine. Arch Oral Biol. 2014;59(2):119\\u0026ndash;24.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eArslandaş Din\\u0026ccedil;t\\u0026uuml;rk B, Şahin Mantı A, Kedici Alp C, Altuğ Yıldırım A, Kaya Mumcu A. Improving the Push-Out Bond Strength of Fiber Posts in Diabetic Dentin: The Role of Chlorexidine Irrigation and Resin Cements. J Funct Biomater. 2024;16(1):4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eViapiana R, Flumignan DL, Guerreiro-Tanomaru JM, Camilleri J, Tanomaru-Filho M. Physicochemical and mechanical properties of zirconium oxide and niobium oxide modified Portland cement-based experimental endodontic sealers. Int Endod J. 2014;47(5):437\\u0026ndash;48.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMann NS, Mann NK, Kapur R. Evaluating the penetration efficacy of calcium silicate-based bioceramic sealers into dentinal tubules with cold lateral compaction technique using confocal laser scanning microscopy: An in vitro study. J Conserv Dent Endod. 2025;28(2):150\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCimpean SI, Burtea ALC, Chiorean RS, Dudescu MC, Antoniac A, Robu A, et al. Evaluation of Bond Strength of Four Different Root Canal Sealers. Mater (Basel). 2022;15(14):4966.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKhoury S, Aranda-Verd\\u0026uacute; S, Casino-Alegre A, Rubio-Climent J, Cruz-Roddriguez JA, Pallar\\u0026eacute;s-Sabater A. Comparison of the push-out bond strength of two hydraulic calcium silicate-based endodontic sealers and an epoxy resin-based sealer. J Clin Exp Dent. 2023;15(10):e804\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAraujo VLC, Cruvinel PB, Palma-Dibb RG, Gariba-Silva R. In vitro bond strength of an epoxy resin-based root canal sealer to root dentin irradiated with high-power lasers and adhesive interface analyses. Lasers Med Sci. 2018;33(2):271\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChen WP, Chen YY, Huang SH, Lin CP. Limitations of push-out test in bond strength measurement. J Endod. 2013;39(2):283\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Bioceramic Sealer, Dentin Adhesion, Diabetes Mellitus, Root Canal Obturation, Push-Out Bond Strength\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8960277/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8960277/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eThis study evaluated the comparative performance of different root canal obturation approaches using different sealer materials on the push-out bond strength of dentin samples obtained from patients with diabetes mellitus (DM).\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eA total of 40 single-rooted mandibular premolars were instrumented using the Reciproc R40 system and randomly assigned to four groups (n\\u0026thinsp;=\\u0026thinsp;10 teeth each): (1) cold lateral compaction with AH Plus, (2) warm vertical compaction with AH Plus, (3) hydraulic single-cone obturation with gutta-percha and Bioserra sealer, and (4) sealer-only technique using the Bioserra bioceramic sealer. After storage at 37\\u0026deg;C and 100% humidity for one week, 1-mm slices were prepared from the coronal, middle, and apical thirds and subjected to push-out testing. Data were analyzed using ANOVA and Tukey\\u0026rsquo;s test (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05).\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eSignificant differences in push-out bond strength were observed among the obturation approaches employing different sealer materials (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05). Bioceramic sealers exhibited higher bond strengths than epoxy resin\\u0026ndash;based sealers, particularly in the middle and apical thirds. Hydraulic single-cone and bioceramic sealer-only approaches outperformed conventional techniques (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), whereas no significant difference was observed between cold lateral and warm vertical compaction.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eObturation approaches employing bioceramic sealers demonstrated superior bonding in diabetic dentin, suggesting potential advantages over conventional methods within the context of diabetic dentin.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Comparative Evaluation of Root Canal Obturation Techniques and Sealers in Diabetic Dentin: An in-vitro Push-Out Bond Strength Test\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-03-08 16:23:30\",\"doi\":\"10.21203/rs.3.rs-8960277/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"5424fa7e-e876-4853-b471-040571a077a2\",\"owner\":[],\"postedDate\":\"March 8th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-18T08:42:14+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-03-08 16:23:30\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8960277\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8960277\",\"identity\":\"rs-8960277\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}