Effect of intracanal medicament on dentin penetration ability of root canal sealers: A confocal study

Effect of intracanal medicament on dentin penetration ability of root canal sealers: A confocal study | 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 Effect of intracanal medicament on dentin penetration ability of root canal sealers: A confocal study Emre Bayram, H. Melike Bayram This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6368495/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Jul, 2025 Read the published version in BMC Oral Health → Version 1 posted 13 You are reading this latest preprint version Abstract Background This study investigated the effect of three intracanal medicaments on the penetration ability of three different root canal sealers using confocal laser scanning microscopy (CLSM). Materials and Methods 120 extracted single-rooted human teeth were used. The crowns were removed, and each canal was prepared. The teeth were divided into four groups (n=30): three medicament groups (calcium hydroxide (CH), triple antibiotic paste (TAP), and double antibiotic paste [DAP]) and one control group. 0.1% Rhodamine B was incorporated. After three weeks, the medicaments were removed, and then canals were filled with one of the following sealers: AHplus, MTAFillapex, and TotalFill (n=10). Fluorescein dye was added to the sealers. Horizontal sections (1 mm thick) were taken from the coronal, middle, and apical portions of each canal. Samples were then viewed under CLSM. Statistical analysis was performed using Kruskal Wallis and Mann-Whitney U tests. Results No statistically significant differences were found for the percentages of penetration of the sealers (p>.05). Regarding the maximum penetration values, there was a significant decrease for root canal sealers except for the Ah plus in the CH group (p<.05). Conclusions Medicaments don’t significantly reduce the average penetration values of sealers. AH Plus dentin penetration confocal microscopy intracanal medicament root canal sealer Figures Figure 1 Figure 2 Introduction Successful endodontic treatment requires thorough mechanical preparation of the root canal, chemical disinfection using irrigating solutions, and a hermetic seal to prevent reinfection [ 1 ]. In addition to mechanical preparation, irrigation solutions help disinfect areas that instruments cannot reach (e.g., dentinal tubules, accessory canals, apical deltas, and canal anastomoses) [ 1 ]. Moreover, intra-canal medicaments provide prolonged and more effective antibacterial activity [ 2 ]. In endodontic treatment, calcium hydroxide (CH) pastes and triple or double antibiotic pastes (TAP/DAP) are commonly used as intracanal medicaments [ 3 ]. CH is favored for its broad antimicrobial efficiency against various bacterial species in endodontic infections and its ability to promote hard tissue formation [ 3 ]. Because, root canal infections often involve mixed microbial communities, using antibiotic combinations is recommended [ 4 ]. Triple antibiotic paste (TAP) typically contains equal proportions of ciprofloxacin, metronidazole, and minocycline [ 3 , 4 ]. Although TAP is reported to be both biocompatible and antimicrobial [ 5 , 6 ], the minocycline component has been associated with visible crown discoloration [ 7 , 8 ]. Consequently, minocycline was removed from TAP, resulting in a double antibiotic paste (DAP) formulation, which includes only ciprofloxacin and metronidazole [ 9 ]. Neither antibiotics nor calcium hydroxide medicament can be completely eliminated from the complex anatomy of the root canal system, which may adversely impact subsequent stages of endodontic therapy [ 10 – 12 ]. Residual medicaments, whether composed of antibiotics or CH, can persist in areas such as lateral canals, dentinal tubules, and isthmuses where irrigating solutions and mechanical instruments have limited access [ 11 ]. Several studies have demonstrated that clinically relevant concentrations of triple antibiotic paste (TAP), double antibiotic paste (DAP), and CH exhibit cytotoxic effects on human dental stem cells and apical papilla pulp cells [ 13 , 14 ], and may elicit moderate inflammatory responses when placed in subcutaneous tissues [ 6 ]. These remnants can also create a physical and/or chemical barrier between the dentinal walls and the subsequently placed sealer, thereby hindering the sealer’s ability to penetrate and adapt to the tubules [ 15 , 16 ]. Inadequate penetration may compromise the hermetic seal required for long-term endodontic success by allowing microleakage, bacterial ingress, or recontamination of the canal system. Although various irrigation and activation protocols—such as ultrasonic or sonic agitation—have been proposed to enhance the removal of intracanal medicaments, complete removal remains a challenge [ 15 , 16 ]. Confocal laser scanning microscopy (CLSM) is widely used in endodontics to evaluate sealer penetration into dentinal tubules, asses canal filling techniques, and determine the effects of various irrigation protocols at different root levels (apical, middle, and coronal) [ 17 , 18 ]. In light of this information, although push-out bond strength studies have investigated the interaction between residual intracanal medicaments and root canal filling materials, to the best of our knowledge, no published research has employed confocal laser scanning microscopy to visualize and measure quantitatively this interface for all three medicaments. This study aimed to investigate how intracanal medicaments influence the dentinal penetration of different root canal sealers by means of confocal laser microscopy. The null hypothesis is that no significant difference would be observed in sealer penetration among the tested medicament groups. Materials and Methods G*Power software (version 3.1, Heinrich Heine University, Düsseldorf, Germany) was used with a significance level (α) of 0.05, a statistical power (1-β) of 0.80, and an effect size of 0.25. 120 extracted single-rooted human teeth were collected from the Department of Oral and Maxillofacial Surgery, with informed consent obtained from the patients for using their extracted teeth for research purposes. The extractions were performed for reasons unrelated to this study, such as orthodontic or periodontal indications. All procedures complied with relevant ethical guidelines, and the study protocol was approved by the institutional ethics committee. Following extraction, the teeth were stored in thymol. Under the operating microscope, any specimens presenting fractures, cracks, or other defects were excluded. Residual hard and soft tissues were carefully removed, and the teeth were kept in saline until further use. The crowns were removed, so the remaining root portion measured 15 mm long. # 10 Type K file (Diadent, Burnaby, BC, Canada) was introduced into the canal until it was visible at the apical foramen, and the working length was established by subtracting 1 mm shorter from this point. Root canal preparation was performed using the Reciproc (VDW) rotary file system to R40. During the instrumentation, 2 ml of 2.5% sodium hypochlorite (NaOCl) (Ace, Procter & Gamble, Istanbul, Turkey) was used as the primary irrigant. Subsequently, 5 ml of 17% EDTA (Sigma Chemical Co., St Louis, MO, USA) and 5 ml of distilled water were employed as final irrigants. After drying the canals with paper points, the specimens were randomly divided into four groups according to the type of medicament (n = 30). During the preparation of the root canal sealer, 0.1% Rhodamine B dye (red) was added to allow CLSM evaluation before the sealer placement into the canal. In the first group, the CaOH was used; in the second group, TAP; and in the third group, DAP. Each paste was mixed with distilled water and introduced into the root canal using a lentulo spiral. No medicament was applied in the fourth group, serving as the control. The canal orifices were then sealed with cotton pellets and temporary filling material (Cavit,3 M ESPE AG, Seefeld, Germany), and all samples were stored for three weeks at 37 ° C in a 100% humidity environment. To remove intra-canal medicaments, 5mL of 5% NaOCl and 5mL of 17% EDTA were used alongside passive ultrasonic activation for 60 seconds. Subsequently, each canal was subdivided into three subgroups, to be obturated with one of three different root canal sealers. Fluorescein dye (green) was added to these sealers to distinguish them from the medicament traces. The root canals were then filled with Resiproc 40 gutta-percha cones and one of the following sealers: AH Plus (Dentsply DeTrey GmbH, Konstanz, Germany), MTA Fillapex (Angelus, Londrina, PR, Brazil), and Total Fill (FKG Dentaire, La Chaux-de-Fonds, Switzerland) canal sealers (n = 10). The filled samples were incubated at 37 ° C in 100% humidity for one week to ensure a complete sealer setting. The prepared samples were embedded in acrylic resin using cylindrical molds and sectioned with an ISOMET 4000 (Buehler, IL, USA) low-speed saw equipped with 0.3 mm thick diamond discs under water cooling. Three horizontal slices, each approximately 1 mm thick, were obtained at 3, 5, and 7 mm from the coronal region. The thickness of each slice was verified using a digital caliper. A confocal laser scanning microscope (Zeiss LSM 510, Carl Zeiss, Göttingen, Germany) with an argon laser light source (Wavelength: 514 nm) was used to visualize the penetration of both medicaments and sealers into the dentinal tubules. Images were recorded at a resolution of 512x512 pixels under 10X magnification (EC Plan-Neofluar Lens), then transferred to Zeiss LSM Image Browser v.4.2.0 (Carl Zeiss MicroImaging GmbH 1997–2006) for analysis. The penetration percentage was determined according to the method described by Gharib et al. [ 19 ], similar to the method (Fig. 1 ). Briefly, the perimeter of the canal wall was outlined using the software’s drawing tools, and areas demonstrating tubular penetration were demarcated was measured. The ratio of the penetrated area’s length to the total canal perimeter yielded the penetration percentage. Additionally, the deepest and average depths were recorded for each specimen. Statistical Analysis All statistical evaluations were performed using SPSS for Windows 20.0 (IBM, Armonk, NY, USA). The Shapiro-Wilk test was employed to assess whether the data followed a normal distribution, and Levene’s test was used to evaluate the homogeneity of variances. Differences in median values among the groups were examined using the Kruskal-Wallis test. When the Kruskal Wallis test indicated a significant result, the Mann-Whitney U test with Bonferroni correction was applied to identify the groups responsible for the observed differences. A p-value < 0.05 was considered statistically significant. Results This study assessed three different intracanal medicaments and three different sealers regarding dentinal tubule penetration area, maximum penetration depth, and canal wall penetration percentage. Statistical analysis revealed no significant differences among the groups regarding the dentinal tubule penetration area (p > 0.05). Although TotalFill exhibited the greatest penetration and MTA Fillapex the least, these differences were not statistically significant. Similarly, there were no significant variations in maximum penetration depth (p > 0.05). With respect to the percentage of penetration along the canal wall, TotalFill once again showed the highest values, and AH Plus the lowest; however, these differences also did not reach statistical significance (p > 0.05). Table 1 summarizes the dentin penetration percentages for the tested root canal sealers, along with their maximum and mean penetration depths. Representative CLSM images illustrating these findings are presented in Fig. 2 . Table 1: The mean and standard deviation values of the penetration percentage (%), and mean-maximum penetration (µm) amounts of root canal sealants in the medicaments and areas Penetration(%) Average Penetration( µm) Maksimum Penetration( µm) Coronal Middle Apical Coronal Middle Apical Coronal Middle Apical AH Plus CaOH 34±15 A,a 44±18 A,a 13±9 B,a 315±127 A,a 148±86 B,a 227±133 AB,a 580±254 A,a 272±149 B,a 404±267 AB,a DAP 66±7 A,b 53±10 B,a 15±10 C,a 284±109 AB,a 355±62 B,b 170±164 A,a 518±217 A,a 661±123 B,c 416±258 A,a TAP 46±11 A,a 46±18 A,a 33±10 A,b 313±154 A,a 391±138 A,b 279±103 A,a 640±231 A,a 731±275 A,bc 508±207 A,a Control 69±10 A,b 67±15 A,b 23±14 B,ab 295±81 A,a 440±108 B,b 267±108 A,a 541±162 A,a 842±156 B,c 485±216 A,a MTA Fillapex CaOH 60±22 A,ab 54±21 A,ab 37±19 A,a 255±141 A,a 303±162 A,ab 295±59 A,a 460±283 A,a 556±323 A,ab 642±152 A,a DAP 59±7 A,a 44±16 A,a 26±18 B,a 221±107 A,a 314±71 B,a 160±88 A,a 392±214 A,a 679±138 B,a 270±176 A,b TAP 64±11 A,ab 48±10 B,a 30±25 B,a 257±125 A,a 210±103 A,b 292±83 A,a 515±190 A,a 370±207 A,b 682±153 B,a Control 72±13 A,b 64±12 A,b 38±18 B,a 566±156 A,b 336±103 B,a 231±88 C,a 973±150 A,b 622±206 B,a 411±176 C,b Total Fill CaOH 63±7 A,ab 49±21 A,a 20±11 B,ac 265±56 A,a 316±147 A,ab 133±81 B,a 481±111 A,a 581±294 A,a 270±115 B,a DAP 65±6 A,a 56±20 A,ab 11±8 B,b 416±133 A,b 424±63 A,b 156±68 B,a 783±267 A,b 727±134 A,a 262±135 B,a TAP 67±6 A,a 68±9 A,b 13±10 B,ab 330±108 B,ab 286±128 AB,a 202±200 A,ab 610±216 B,ab 521±256 AB,a 393±379 A,ab Control 57±8 A,b 51±17 A,a 27±11 B,c 390±102 A,b 391±138 A,ab 231±87 B,b 731±204 A,b 731±275 A,a 458±153 B,b Different uppercase superscripts indicate differences between regions (intercolumns) in the same root canal sealer and medicament p<.05. Different lowercase superscripts indicate differences (between lines) between medicaments in the same region and sealer p<.05. Discussion Following chemomechanical preparation, various strategies have been introduced to eliminate or reduce residual microorganisms within the root canal system, particularly in the dentinal tubules. Intracanal medicaments are commonly recommended in cases of apical periodontitis and necrotic pulp to enhance microbial control. Among these, calcium hydroxide, triple antibiotic paste, and double antibiotic paste are widely utilized worldwide; however, their complete removal before root canal obturation remains crucial [ 2 ]. Previous research suggests that residual intracanal medicaments may influence the ability of sealers to penetrate dentinal tubules during root canal filling [ 8 ]. Understanding whether and to what extent sealers infiltrate the tubules is critical for successful endodontic outcomes. In this context, the present study aimed to determine the impact of various medicaments on the dentinal penetration of different sealers, given that residual medicaments have been reported to hinder sealer infiltration. Notably, this constitutes the first in vitro study employing CLSM to evaluate the dentinal penetration of three distinct sealer formulations after removing three different intracanal medicaments. Various analytical techniques have been employed to evaluate sealer penetration, including stereomicroscopy [ 20 ], scanning electron microscopy [ 21 ], and, more recently, confocal laser scanning microscopy [ 22 , 23 ]. CLSM has proven beneficial for comparing the dentinal tubule infiltration of different sealers, assessing the effects of various obturation techniques, and examining the distribution of filling materials in the coronal, middle, and apical third regions [ 18 ]. Bitter et al. found that CLSM offers a more detailed view of dentin-bound paste than scanning electron microscopy [ 24 ]. Hence, CLSM was chosen in the present study to achieve a more comprehensive analysis of sealer penetration. The use of fluorescent dyes substantially enhances material visibility under CLSM [ 17 , 18 ]. In this study, Rhodamine B dye was incorporated into the intracanal medicaments, while Fluorescein was added to the sealers, enabling clear differentiation between the two substances during confocal imaging. Previous investigations have employed this dual-dye approach to assessing sealer penetration into dentinal tubules [ 22 , 23 , 25 ]. Numerous studies have emphasized the challenge of thoroughly eliminating intracanal medicaments, especially in the apical third of the root canal system [ 18 , 25 , 26 ]. A previous review reported that ultrasonically activated irrigation is particularly effective in removing Ca(OH) 2 from the apical third [ 26 ]. Consequently, passive ultrasonic activation and irrigation were applied in this study to facilitate more efficient removal of intracanal medicaments, consistent with earlier findings [ 26 ]. In the present study, all tested sealers exhibited greater penetration in the coronal direction compared to the apical third. Similarly, Kok et al. reported that MTA Fillapex and AH Plus showed notably reduced tubule penetration in the apical region after endodontic retreatment [ 27 ]. Aydın et al. also observed that, under CLSM, the coronal sections achieved a higher percentage of sealer infiltration than the apical sections [ 18 ]. These regional variations may be attributed to several factors, including tubular obliteration in the apical third [ 28 ], a higher density and larger diameter of tubules in the coronal and middle thirds [ 28 ], conical anatomy of the root canal, and the presence of debris or medicament remnants near the apex [ 29 ]. The present findings indicate that although sealer penetration was reduced following the application of intracanal medicaments, this decrease did not reach statistical significance compared to the control group. These results suggest that the chosen removal protocol- which included passive ultrasonic activation- was sufficiently effective to minimize residual medicaments within the canal, thereby preventing any marked impediment to the penetration of AH plus, MTA Fillapex, or TotalFill sealers. This observation aligns with previous research highlighting the importance of meticulous cleaning protocols to mitigate the adverse effects of medicament remnants on both sealer adaptation and overall penetration, as well as ensuring long-term endodontic success [ 30 , 31 ]. Moreover, certain physical and chemical properties of epoxy resin-based and bioceramic sealers- such as favorable flow characteristics and the ability to chemically interact with dentin- may help them traverse partially obstructed tubules more effectively [ 32 – 34 ]. Conclusion Within the limitations of this in vitro study, the null hypothesis was accepted. Both resin-based and bioceramic sealers achieved acceptable dentinal tubule penetration, even in residual intracanal medicaments, and demonstrated comparable penetration rates. Following thorough medicament removal, obturation with epoxy resin-based and bioceramic sealers may, therefore, enhance the adaptation and overall integrity of the root canal filling. Declarations Funding No funding has been received for this study. Availability of data and material The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. Consent to publication Not applicable to this study. Competing interests The authors declare no competing interests. Acknowledgment Gaziosmanpaşa University Scientific Research Projects Commission supported this study with project number 2016/18. Ethics declarations Ethics approval and consent to participate All procedures performed in studies involving human biological material were by the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the ethics committee of Tokat Gaziosmanpaşa University’s Faculty of Medicine project number 15- KAEK-071. The informed consent form was obtained. Authors’ Contributions Conceptualization Emre Bayram and H.Melike Bayram; writing—original draft preparation Emre Bayram and H.Melike Bayram; writing—review and editing Emre Bayram and H.Melike Bayram; visualization Emre Byram and H.Melike Bayram; supervision Emre Bayram and H.Melike Bayram. All authors have read and agreed to the published version of the manuscript. Corresponding author Correspondence to Hü da Melike Bayram References Berber VB, Gomes BP, Sena NT, Vianna ME, Ferraz CC, Zaia AA, et al. Efficacy of various concentrations of NaOCl and instrumentation techniques in reducing Enterococcus faecalis within root canals and dentinal tubules. Int Endod J. 2006;39:10-7. Krithikadatta J, Indira R, Dorothykalyani AL. Disinfection of dentinal tubules with 2% chlorhexidine, 2% metronidazole, bioactive glass when compared with calcium hydroxide as intracanal medicaments. J of Endod.2007;33:1473-6. Lakhani AA, Sekhar KS, Gupta P, Tejolatha B, Gupta A, Kashyap S, et al. Efficacy of Triple Antibiotic Paste, Moxifloxacin, Calcium Hydroxide And 2% Chlorhexidine Gel In Elimination of E. Faecalis: An In vitro Study. J Clin Diagno Res: JCDR 2017;11:Zc06-zc9. Windley W, 3rd, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth with a triple antibiotic paste. J of Endod.2005;31:439-43. McGurkin-Smith R, Trope M, Caplan D, Sigurdsson A. Reduction of intracanal bacteria using GT rotary instrumentation, 5.25% NaOCl, EDTA, and Ca(OH)2. J of Endod.2005;31:359-63. Gomes-Filho JE, Duarte PC, de Oliveira CB, Watanabe S, Lodi CS, Cintra LT, et al. Tissue reaction to a triantibiotic paste used for endodontic tissue self-regeneration of nonvital immature permanent teeth. J of Endod.2012;38:91-4. Miller EK, Lee JY, Tawil PZ, Teixeira FB, Vann WF, Jr. Emerging therapies for the management of traumatized immature permanent incisors. Pediat Dent. 2012;34:66-9. Akcay M, Arslan H, Yasa B, Kavrık F, Yasa E. Spectrophotometric analysis of crown discoloration induced by various antibiotic pastes used in revascularization. J of Endod. 2014;40:845-8. Hargreaves KM, Diogenes A, Teixeira FB. Treatment options: biological basis of regenerative endodontic procedures. J of Endod.2013;39:S30-43. Arslan H, Akcay M, Capar ID, Ertas H, Ok E, Uysal B. Efficacy of needle irrigation, EndoActivator, and photon-initiated photoacoustic streaming technique on removal of double and triple antibiotic pastes. J of Endod.2014;40:1439-42. Chou K, George R, Walsh LJ. Effectiveness of different intracanal irrigation techniques in removing intracanal paste medicaments. Aust Endod J. 2014;40:21-5. Berkhoff JA, Chen PB, Teixeira FB, Diogenes A. Evaluation of triple antibiotic paste removal by different irrigation procedures. J of Endod. 2014;40:1172-7. Ruparel NB, Teixeira FB, Ferraz CC, Diogenes A. Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. J of Endod. 2012;38:1372-5. Labban N, Yassen GH, Windsor LJ, Platt JA. The direct cytotoxic effects of medicaments used in endodontic regeneration on human dental pulp cells. Dent Trauma.2014;30:429-34. Arslan H, Capar ID, Saygili G, Uysal B, Gok T, Ertas H, et al. Efficacy of various irrigation protocols on the removal of triple antibiotic paste. Int Endod J.2014;47:594-9. Guiotti FA, Kuga MC, Duarte MA, Sant'Anna AJ, Faria G. Effect of calcium hydroxide dressing on push-out bond strength of endodontic sealers to root canal dentin. Braz Oral Res. 2014;28. Gunes B, Yeter KY, Terlemez A, Seker B, Altay Y. Dentinal tubule penetration of endodontic sealers after nonthermal plasma treatment: A confocal laser scanning microscopy study. Micros Res and Techn. 2019;82:903-8. Aydın ZU, Özyürek T, Keskin B, Baran T. Effect of chitosan nanoparticle, QMix, and EDTA on TotalFill BC sealers' dentinal tubule penetration: a confocal laser scanning microscopy study. Odonto. 2019;107:64-71. Gharib SR, Tordik PA, Imamura GM, Baginski TA, Goodell GG. A confocal laser scanning microscope investigation of the epiphany obturation system. J of Endod.2007;33:957-61. Deniz Sungur D, Aksel H, Purali N. Effect of a Low Surface Tension Vehicle on the Dentinal Tubule Penetration of Calcium Hydroxide and Triple Antibiotic Paste. J of Endod.2017;43:452-5. Mamootil K, Messer HH. Penetration of dentinal tubules by endodontic sealer cements in extracted teeth and in vivo. Int Endod J. 2007;40:873-81. Russell A, Friedlander L, Chandler N. Sealer penetration and adaptation in root canals with the butterfly effect. Aust Endod J. 2018;44:225-34. Machado MEL, Veintimilla Lozada VN, Carrillo Rengifo KJ, Guillén REG, Caballero-Flores H, Nabeshima CK. Confocal laser scanning microscopic analysis of the penetration of an epoxy resin-based sealer into dentinal tubules after calcium hydroxide dressing. Aust Endod J. 2021;47:480-6. Bitter K, Paris S, Mueller J, Neumann K, Kielbassa AM. Correlation of scanning electron and confocal laser scanning microscopic analyses for visualization of dentin/adhesive interfaces in the root canal. J of Adhes Dent. 2009;11:7-14. Uzunoglu-Özyürek E, Erdoğan Ö, Aktemur Türker S. Effect of Calcium Hydroxide Dressing on the Dentinal Tubule Penetration of 2 Different Root Canal Sealers: A Confocal Laser Scanning Microscopic Study. J of Endod. 2018;44:1018-23. Zorzin J, Wießner J, Wießner T, Lohbauer U, Petschelt A, Ebert J. Removal of Radioactively Marked Calcium Hydroxide from the Root Canal: Influence of Volume of Irrigation and Activation. J of Endod. 2016;42:637-40. Kok D, Rosa RA, Barreto MS, Busanello FH, Santini MF, Pereira JR, et al. Penetrability of AH plus and MTA fillapex after endodontic treatment and retreatment: a confocal laser scanning microscopy study. Micros Res And Techn. 2014;77:467-71. Mjör IA, Smith MR, Ferrari M, Mannocci F. The structure of dentine in the apical region of human teeth. Int Endod J. 2001;34:346-53. Castagna F, Rizzon P, da Rosa RA, Santini MF, Barreto MS, Duarte MA, et al. Effect of passive ultrassonic instrumentation as a final irrigation protocol on debris and smear layer removal--a SEM analysis. Micros Res And Techn. 2013;76:496-502. Gokturk H, Bayram E, Bayram HM, Aslan T, Ustun Y. Effect of double antibiotic and calcium hydroxide pastes on dislodgement resistance of an epoxy resin-based and two calcium silicate-based root canal sealers. Clin Oral Investig. 2017;21:1277-82. Sarıyılmaz Ö, Uslu G, Sarıyılmaz E, Keskin NB. Evaluation of different irrigation activation techniques for the removal of various medicaments from a simulated internal resorption cavity: an in vitro study. Clin Oral Investig. 2024;28:491. Quaresma SAL, Alves Dos Santos GN, Silva-Sousa AC, Camargo RV, Lopes-Olhê FC, Silva-Sousa YTC, et al. Physicochemical properties of calcium silicate cement based endodontic sealers. Journal of the mechanical behavior of biomedical materials. 2024;151:106400. Yan Y, Li Y, Chi Y, Ji M, Shen Y, Zou L. A comparative study of biological properties of three root canal sealers. Clin Oral Investig. 2023;28:11. Ashkar I, Sanz JL, Forner L, Ghilotti J, Melo M. A Literature Review of the Effect of Heat on the Physical-Chemical Properties of Calcium Silicate-Based Sealers. J of Endod.2024;50:1044-58.e5. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Jul, 2025 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 09 Jun, 2025 Reviews received at journal 05 Jun, 2025 Reviewers agreed at journal 05 Jun, 2025 Reviews received at journal 29 May, 2025 Reviewers agreed at journal 29 May, 2025 Reviews received at journal 13 May, 2025 Reviewers agreed at journal 29 Apr, 2025 Reviewers agreed at journal 29 Apr, 2025 Reviewers invited by journal 29 Apr, 2025 Editor assigned by journal 28 Apr, 2025 Editor invited by journal 17 Apr, 2025 Submission checks completed at journal 17 Apr, 2025 First submitted to journal 17 Apr, 2025 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6368495","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449639482,"identity":"1d4e793d-0d14-4fe4-98cd-63e7d787bcb3","order_by":0,"name":"Emre Bayram","email":"","orcid":"","institution":"Tokat Gaziosmanpasa University","correspondingAuthor":false,"prefix":"","firstName":"Emre","middleName":"","lastName":"Bayram","suffix":""},{"id":449639483,"identity":"a1701f40-b5b9-48ae-858e-9aec63e1f8c9","order_by":1,"name":"H. Melike Bayram","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYFAC5oaDDQwMMkAW4wMGhgPEaGEEa+EBaTYgWgsjVAubBFFadNsbGw/OqLDj4W8//Kyap+aOHD8D88NHN/BoMTtzsOHghjPJPBJn0sxu8xx7ZizZwGZsnINPy43EhoMP25h5GG4wALWwHU7ccICHTRqvlvsPgVr+1fPI32D/VszzjxgtN4AhtrHhMI/BDR4zZt42YrScATpsxrHjPIZncool5/YdNpZsJuSX44cPf+ypqZaTO35844c33w7L8bM3P3yMTwsKYALFDgMzscpBgPEHKapHwSgYBaNgxAAAjbRV0Et0AGcAAAAASUVORK5CYII=","orcid":"","institution":"Tokat Gaziosmanpasa University","correspondingAuthor":true,"prefix":"","firstName":"H.","middleName":"Melike","lastName":"Bayram","suffix":""}],"badges":[],"createdAt":"2025-04-03 10:38:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6368495/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6368495/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-025-06657-0","type":"published","date":"2025-07-26T15:58:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81929612,"identity":"f4036464-ec6a-4c4b-9345-44d177c9bfc3","added_by":"auto","created_at":"2025-05-05 05:00:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":310287,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of dentin tubule penetration area [19]\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6368495/v1/9db237466e1dd6b82a62d8fd.png"},{"id":81929613,"identity":"eb2e7437-5b47-46e5-bb7d-f09fbe6c6710","added_by":"auto","created_at":"2025-05-05 05:00:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":476190,"visible":true,"origin":"","legend":"\u003cp\u003eDentin tubule penetrations visualized with CLSM\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6368495/v1/5b461a5c1614185d50da5b72.png"},{"id":87756759,"identity":"81a0af05-4c97-4eeb-b1af-308965ba3fdd","added_by":"auto","created_at":"2025-07-28 16:08:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1540652,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6368495/v1/72a4790c-73bf-4549-8cb4-eed2964eed20.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of intracanal medicament on dentin penetration ability of root canal sealers: A confocal study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSuccessful endodontic treatment requires thorough mechanical preparation of the root canal, chemical disinfection using irrigating solutions, and a hermetic seal to prevent reinfection [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition to mechanical preparation, irrigation solutions help disinfect areas that instruments cannot reach (e.g., dentinal tubules, accessory canals, apical deltas, and canal anastomoses) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Moreover, intra-canal medicaments provide prolonged and more effective antibacterial activity [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn endodontic treatment, calcium hydroxide (CH) pastes and triple or double antibiotic pastes (TAP/DAP) are commonly used as intracanal medicaments [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. CH is favored for its broad antimicrobial efficiency against various bacterial species in endodontic infections and its ability to promote hard tissue formation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Because, root canal infections often involve mixed microbial communities, using antibiotic combinations is recommended [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Triple antibiotic paste (TAP) typically contains equal proportions of ciprofloxacin, metronidazole, and minocycline [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although TAP is reported to be both biocompatible and antimicrobial [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], the minocycline component has been associated with visible crown discoloration [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Consequently, minocycline was removed from TAP, resulting in a double antibiotic paste (DAP) formulation, which includes only ciprofloxacin and metronidazole [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNeither antibiotics nor calcium hydroxide medicament can be completely eliminated from the complex anatomy of the root canal system, which may adversely impact subsequent stages of endodontic therapy [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Residual medicaments, whether composed of antibiotics or CH, can persist in areas such as lateral canals, dentinal tubules, and isthmuses where irrigating solutions and mechanical instruments have limited access [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Several studies have demonstrated that clinically relevant concentrations of triple antibiotic paste (TAP), double antibiotic paste (DAP), and CH exhibit cytotoxic effects on human dental stem cells and apical papilla pulp cells [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and may elicit moderate inflammatory responses when placed in subcutaneous tissues [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These remnants can also create a physical and/or chemical barrier between the dentinal walls and the subsequently placed sealer, thereby hindering the sealer\u0026rsquo;s ability to penetrate and adapt to the tubules [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Inadequate penetration may compromise the hermetic seal required for long-term endodontic success by allowing microleakage, bacterial ingress, or recontamination of the canal system. Although various irrigation and activation protocols\u0026mdash;such as ultrasonic or sonic agitation\u0026mdash;have been proposed to enhance the removal of intracanal medicaments, complete removal remains a challenge [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConfocal laser scanning microscopy (CLSM) is widely used in endodontics to evaluate sealer penetration into dentinal tubules, asses canal filling techniques, and determine the effects of various irrigation protocols at different root levels (apical, middle, and coronal) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn light of this information, although push-out bond strength studies have investigated the interaction between residual intracanal medicaments and root canal filling materials, to the best of our knowledge, no published research has employed confocal laser scanning microscopy to visualize and measure quantitatively this interface for all three medicaments. This study aimed to investigate how intracanal medicaments influence the dentinal penetration of different root canal sealers by means of confocal laser microscopy. The null hypothesis is that no significant difference would be observed in sealer penetration among the tested medicament groups.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eG*Power software (version 3.1, Heinrich Heine University, D\u0026uuml;sseldorf, Germany) was used with a significance level (α) of 0.05, a statistical power (1-β) of 0.80, and an effect size of 0.25. 120 extracted single-rooted human teeth were collected from the Department of Oral and Maxillofacial Surgery, with informed consent obtained from the patients for using their extracted teeth for research purposes. The extractions were performed for reasons unrelated to this study, such as orthodontic or periodontal indications. All procedures complied with relevant ethical guidelines, and the study protocol was approved by the institutional ethics committee. Following extraction, the teeth were stored in thymol. Under the operating microscope, any specimens presenting fractures, cracks, or other defects were excluded. Residual hard and soft tissues were carefully removed, and the teeth were kept in saline until further use. The crowns were removed, so the remaining root portion measured 15 mm long. # 10 Type K file (Diadent, Burnaby, BC, Canada) was introduced into the canal until it was visible at the apical foramen, and the working length was established by subtracting 1 mm shorter from this point. Root canal preparation was performed using the Reciproc (VDW) rotary file system to R40. During the instrumentation, 2 ml of 2.5% sodium hypochlorite (NaOCl) (Ace, Procter \u0026amp; Gamble, Istanbul, Turkey) was used as the primary irrigant. Subsequently, 5 ml of 17% EDTA (Sigma Chemical Co., St Louis, MO, USA) and 5 ml of distilled water were employed as final irrigants.\u003c/p\u003e \u003cp\u003eAfter drying the canals with paper points, the specimens were randomly divided into four groups according to the type of medicament (n\u0026thinsp;=\u0026thinsp;30). During the preparation of the root canal sealer, 0.1% Rhodamine B dye (red) was added to allow CLSM evaluation before the sealer placement into the canal. In the first group, the CaOH was used; in the second group, TAP; and in the third group, DAP. Each paste was mixed with distilled water and introduced into the root canal using a lentulo spiral. No medicament was applied in the fourth group, serving as the control. The canal orifices were then sealed with cotton pellets and temporary filling material (Cavit,3 M ESPE AG, Seefeld, Germany), and all samples were stored for three weeks at 37 \u0026deg; C in a 100% humidity environment. To remove intra-canal medicaments, 5mL of 5% NaOCl and 5mL of 17% EDTA were used alongside passive ultrasonic activation for 60 seconds. Subsequently, each canal was subdivided into three subgroups, to be obturated with one of three different root canal sealers. Fluorescein dye (green) was added to these sealers to distinguish them from the medicament traces. The root canals were then filled with Resiproc 40 gutta-percha cones and one of the following sealers: AH Plus (Dentsply DeTrey GmbH, Konstanz, Germany), MTA Fillapex (Angelus, Londrina, PR, Brazil), and Total Fill (FKG Dentaire, La Chaux-de-Fonds, Switzerland) canal sealers (n\u0026thinsp;=\u0026thinsp;10). The filled samples were incubated at 37 \u0026deg; C in 100% humidity for one week to ensure a complete sealer setting.\u003c/p\u003e \u003cp\u003eThe prepared samples were embedded in acrylic resin using cylindrical molds and sectioned with an ISOMET 4000 (Buehler, IL, USA) low-speed saw equipped with 0.3 mm thick diamond discs under water cooling. Three horizontal slices, each approximately 1 mm thick, were obtained at 3, 5, and 7 mm from the coronal region. The thickness of each slice was verified using a digital caliper. A confocal laser scanning microscope (Zeiss LSM 510, Carl Zeiss, G\u0026ouml;ttingen, Germany) with an argon laser light source (Wavelength: 514 nm) was used to visualize the penetration of both medicaments and sealers into the dentinal tubules. Images were recorded at a resolution of 512x512 pixels under 10X magnification (EC Plan-Neofluar Lens), then transferred to Zeiss LSM Image Browser v.4.2.0 (Carl Zeiss MicroImaging GmbH 1997\u0026ndash;2006) for analysis. The penetration percentage was determined according to the method described by Gharib et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], similar to the method (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Briefly, the perimeter of the canal wall was outlined using the software\u0026rsquo;s drawing tools, and areas demonstrating tubular penetration were demarcated was measured. The ratio of the penetrated area\u0026rsquo;s length to the total canal perimeter yielded the penetration percentage. Additionally, the deepest and average depths were recorded for each specimen.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical evaluations were performed using SPSS for Windows 20.0 (IBM, Armonk, NY, USA). The Shapiro-Wilk test was employed to assess whether the data followed a normal distribution, and Levene\u0026rsquo;s test was used to evaluate the homogeneity of variances. Differences in median values among the groups were examined using the Kruskal-Wallis test. When the Kruskal Wallis test indicated a significant result, the Mann-Whitney U test with Bonferroni correction was applied to identify the groups responsible for the observed differences. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study assessed three different intracanal medicaments and three different sealers regarding dentinal tubule penetration area, maximum penetration depth, and canal wall penetration percentage. Statistical analysis revealed no significant differences among the groups regarding the dentinal tubule penetration area (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Although TotalFill exhibited the greatest penetration and MTA Fillapex the least, these differences were not statistically significant. Similarly, there were no significant variations in maximum penetration depth (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). With respect to the percentage of penetration along the canal wall, TotalFill once again showed the highest values, and AH Plus the lowest; however, these differences also did not reach statistical significance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the dentin penetration percentages for the tested root canal sealers, along with their maximum and mean penetration depths. Representative CLSM images illustrating these findings are presented in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e The mean and standard deviation values of the penetration percentage (%), and mean-maximum penetration (\u0026micro;m) amounts of root canal sealants in the medicaments and areas\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"782\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePenetration(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage Penetration(\u003c/strong\u003e\u003cstrong\u003e\u0026micro;m)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 210px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaksimum Penetration(\u003c/strong\u003e\u003cstrong\u003e\u0026micro;m)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoronal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMiddle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoronal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMiddle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoronal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMiddle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAH Plus\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaOH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e34\u0026plusmn;15 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e44\u0026plusmn;18 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e13\u0026plusmn;9 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e315\u0026plusmn;127 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e148\u0026plusmn;86 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e227\u0026plusmn;133 \u003csup\u003eAB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e580\u0026plusmn;254 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e272\u0026plusmn;149 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e404\u0026plusmn;267 \u003csup\u003eAB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e66\u0026plusmn;7\u003csup\u003e\u0026nbsp;A,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e53\u0026plusmn;10 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e15\u0026plusmn;10 \u003csup\u003eC,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e284\u0026plusmn;109 \u003csup\u003eAB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e355\u0026plusmn;62\u003csup\u003e\u0026nbsp;B,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e170\u0026plusmn;164 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e518\u0026plusmn;217 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e661\u0026plusmn;123 \u003csup\u003eB,c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e416\u0026plusmn;258 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e46\u0026plusmn;11 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e46\u0026plusmn;18 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e33\u0026plusmn;10 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e313\u0026plusmn;154 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e391\u0026plusmn;138 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e279\u0026plusmn;103 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e640\u0026plusmn;231\u003csup\u003e\u0026nbsp;A,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e731\u0026plusmn;275 \u003csup\u003eA,bc\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e508\u0026plusmn;207 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e69\u0026plusmn;10 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e67\u0026plusmn;15 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e23\u0026plusmn;14 \u003csup\u003eB,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e295\u0026plusmn;81 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e440\u0026plusmn;108 \u003csup\u003eB,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e267\u0026plusmn;108\u003csup\u003e\u0026nbsp;A,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e541\u0026plusmn;162 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e842\u0026plusmn;156 \u003csup\u003eB,c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e485\u0026plusmn;216 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMTA Fillapex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaOH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e60\u0026plusmn;22 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e54\u0026plusmn;21\u003csup\u003e\u0026nbsp;A,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e37\u0026plusmn;19 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e255\u0026plusmn;141 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e303\u0026plusmn;162 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e295\u0026plusmn;59 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e460\u0026plusmn;283 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e556\u0026plusmn;323 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e642\u0026plusmn;152 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e59\u0026plusmn;7 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e44\u0026plusmn;16 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e26\u0026plusmn;18 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e221\u0026plusmn;107 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e314\u0026plusmn;71 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e160\u0026plusmn;88\u003csup\u003e\u0026nbsp;A,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e392\u0026plusmn;214 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e679\u0026plusmn;138 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e270\u0026plusmn;176 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e64\u0026plusmn;11 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e48\u0026plusmn;10 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e30\u0026plusmn;25 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e257\u0026plusmn;125 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e210\u0026plusmn;103 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e292\u0026plusmn;83 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e515\u0026plusmn;190 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e370\u0026plusmn;207 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e682\u0026plusmn;153 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e72\u0026plusmn;13 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e64\u0026plusmn;12 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e38\u0026plusmn;18 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e566\u0026plusmn;156 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e336\u0026plusmn;103 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e231\u0026plusmn;88 \u003csup\u003eC,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e973\u0026plusmn;150 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e622\u0026plusmn;206 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e411\u0026plusmn;176 \u003csup\u003eC,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Fill\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaOH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e63\u0026plusmn;7 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e49\u0026plusmn;21 A,a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e20\u0026plusmn;11 \u003csup\u003eB,ac\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e265\u0026plusmn;56 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e316\u0026plusmn;147 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e133\u0026plusmn;81 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e481\u0026plusmn;111 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e581\u0026plusmn;294 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e270\u0026plusmn;115 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e65\u0026plusmn;6 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e56\u0026plusmn;20 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e11\u0026plusmn;8 \u003csup\u003eB,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e416\u0026plusmn;133 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e424\u0026plusmn;63 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e156\u0026plusmn;68 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e783\u0026plusmn;267\u003csup\u003e\u0026nbsp;A,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e727\u0026plusmn;134 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e262\u0026plusmn;135 \u003csup\u003eB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e67\u0026plusmn;6 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e68\u0026plusmn;9 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e13\u0026plusmn;10 \u003csup\u003eB,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e330\u0026plusmn;108 \u003csup\u003eB,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e286\u0026plusmn;128 \u003csup\u003eAB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e202\u0026plusmn;200 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e610\u0026plusmn;216 \u003csup\u003eB,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e521\u0026plusmn;256 \u003csup\u003eAB,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e393\u0026plusmn;379 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e57\u0026plusmn;8 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e51\u0026plusmn;17 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e27\u0026plusmn;11 \u003csup\u003eB,c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e390\u0026plusmn;102 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e391\u0026plusmn;138 \u003csup\u003eA,ab\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e231\u0026plusmn;87 \u003csup\u003eB,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e731\u0026plusmn;204 \u003csup\u003eA,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e731\u0026plusmn;275 \u003csup\u003eA,a\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e458\u0026plusmn;153 \u003csup\u003eB,b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eDifferent uppercase superscripts indicate differences between regions (intercolumns) in the same root canal sealer and medicament p\u0026lt;.05.\u003c/p\u003e\n \u003cp\u003eDifferent lowercase superscripts indicate differences (between lines) between medicaments in the same region and sealer p\u0026lt;.05.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eFollowing chemomechanical preparation, various strategies have been introduced to eliminate or reduce residual microorganisms within the root canal system, particularly in the dentinal tubules. Intracanal medicaments are commonly recommended in cases of apical periodontitis and necrotic pulp to enhance microbial control. Among these, calcium hydroxide, triple antibiotic paste, and double antibiotic paste are widely utilized worldwide; however, their complete removal before root canal obturation remains crucial [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious research suggests that residual intracanal medicaments may influence the ability of sealers to penetrate dentinal tubules during root canal filling [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Understanding whether and to what extent sealers infiltrate the tubules is critical for successful endodontic outcomes. In this context, the present study aimed to determine the impact of various medicaments on the dentinal penetration of different sealers, given that residual medicaments have been reported to hinder sealer infiltration. Notably, this constitutes the first in vitro study employing CLSM to evaluate the dentinal penetration of three distinct sealer formulations after removing three different intracanal medicaments.\u003c/p\u003e \u003cp\u003eVarious analytical techniques have been employed to evaluate sealer penetration, including stereomicroscopy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], scanning electron microscopy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and, more recently, confocal laser scanning microscopy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. CLSM has proven beneficial for comparing the dentinal tubule infiltration of different sealers, assessing the effects of various obturation techniques, and examining the distribution of filling materials in the coronal, middle, and apical third regions [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Bitter et al. found that CLSM offers a more detailed view of dentin-bound paste than scanning electron microscopy [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Hence, CLSM was chosen in the present study to achieve a more comprehensive analysis of sealer penetration.\u003c/p\u003e \u003cp\u003eThe use of fluorescent dyes substantially enhances material visibility under CLSM [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In this study, Rhodamine B dye was incorporated into the intracanal medicaments, while Fluorescein was added to the sealers, enabling clear differentiation between the two substances during confocal imaging. Previous investigations have employed this dual-dye approach to assessing sealer penetration into dentinal tubules [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNumerous studies have emphasized the challenge of thoroughly eliminating intracanal medicaments, especially in the apical third of the root canal system [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A previous review reported that ultrasonically activated irrigation is particularly effective in removing Ca(OH)\u003csub\u003e2\u003c/sub\u003e from the apical third [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Consequently, passive ultrasonic activation and irrigation were applied in this study to facilitate more efficient removal of intracanal medicaments, consistent with earlier findings [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, all tested sealers exhibited greater penetration in the coronal direction compared to the apical third. Similarly, Kok et al. reported that MTA Fillapex and AH Plus showed notably reduced tubule penetration in the apical region after endodontic retreatment [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Aydın et al. also observed that, under CLSM, the coronal sections achieved a higher percentage of sealer infiltration than the apical sections [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These regional variations may be attributed to several factors, including tubular obliteration in the apical third [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], a higher density and larger diameter of tubules in the coronal and middle thirds [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], conical anatomy of the root canal, and the presence of debris or medicament remnants near the apex [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present findings indicate that although sealer penetration was reduced following the application of intracanal medicaments, this decrease did not reach statistical significance compared to the control group. These results suggest that the chosen removal protocol- which included passive ultrasonic activation- was sufficiently effective to minimize residual medicaments within the canal, thereby preventing any marked impediment to the penetration of AH plus, MTA Fillapex, or TotalFill sealers. This observation aligns with previous research highlighting the importance of meticulous cleaning protocols to mitigate the adverse effects of medicament remnants on both sealer adaptation and overall penetration, as well as ensuring long-term endodontic success [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Moreover, certain physical and chemical properties of epoxy resin-based and bioceramic sealers- such as favorable flow characteristics and the ability to chemically interact with dentin- may help them traverse partially obstructed tubules more effectively [\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWithin the limitations of this in vitro study, the null hypothesis was accepted. Both resin-based and bioceramic sealers achieved acceptable dentinal tubule penetration, even in residual intracanal medicaments, and demonstrated comparable penetration rates. Following thorough medicament removal, obturation with epoxy resin-based and bioceramic sealers may, therefore, enhance the adaptation and overall integrity of the root canal filling.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding has been received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGaziosmanpaşa University Scientific Research Projects Commission supported this study with project number 2016/18.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human biological material were by the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the ethics committee of Tokat Gaziosmanpaşa University’s Faculty of Medicine project number 15- KAEK-071. The informed consent form was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization \u0026nbsp;Emre Bayram and H.Melike Bayram; \u0026nbsp;writing—original draft preparation Emre Bayram and H.Melike Bayram; \u0026nbsp; writing—review and editing \u0026nbsp;Emre Bayram and H.Melike Bayram; \u0026nbsp; visualization \u0026nbsp;Emre Byram and H.Melike Bayram; \u0026nbsp;supervision \u0026nbsp;Emre Bayram and H.Melike Bayram. \u0026nbsp;All authors have read and agreed to the published version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCorresponding author\u003c/p\u003e\n\u003cp\u003eCorrespondence to Hü\u003cu\u003eda Melike Bayram\u003c/u\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u0026nbsp;Berber VB, Gomes BP, Sena NT, Vianna ME, Ferraz CC, Zaia AA, et al. Efficacy of various concentrations of NaOCl and instrumentation techniques in reducing Enterococcus faecalis within root canals and dentinal tubules. Int Endod J. 2006;39:10-7.\u003c/li\u003e\n \u003cli\u003eKrithikadatta J, Indira R, Dorothykalyani AL. Disinfection of dentinal tubules with 2% chlorhexidine, 2% metronidazole, bioactive glass when compared with calcium hydroxide as intracanal medicaments. J of Endod.2007;33:1473-6.\u003c/li\u003e\n \u003cli\u003eLakhani AA, Sekhar KS, Gupta P, Tejolatha B, Gupta A, Kashyap S, et al. Efficacy of Triple Antibiotic Paste, Moxifloxacin, Calcium Hydroxide And 2% Chlorhexidine Gel In Elimination of E. Faecalis: An In vitro Study. J Clin Diagno Res: JCDR 2017;11:Zc06-zc9.\u003c/li\u003e\n \u003cli\u003eWindley W, 3rd, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth with a triple antibiotic paste. J of Endod.2005;31:439-43.\u003c/li\u003e\n \u003cli\u003eMcGurkin-Smith R, Trope M, Caplan D, Sigurdsson A. Reduction of intracanal bacteria using GT rotary instrumentation, 5.25% NaOCl, EDTA, and Ca(OH)2. J of Endod.2005;31:359-63.\u003c/li\u003e\n \u003cli\u003eGomes-Filho JE, Duarte PC, de Oliveira CB, Watanabe S, Lodi CS, Cintra LT, et al. Tissue reaction to a triantibiotic paste used for endodontic tissue self-regeneration of nonvital immature permanent teeth. J of Endod.2012;38:91-4.\u003c/li\u003e\n \u003cli\u003eMiller EK, Lee JY, Tawil PZ, Teixeira FB, Vann WF, Jr. Emerging therapies for the management of traumatized immature permanent incisors. Pediat Dent. 2012;34:66-9.\u003c/li\u003e\n \u003cli\u003eAkcay M, Arslan H, Yasa B, Kavrık F, Yasa E. Spectrophotometric analysis of crown discoloration induced by various antibiotic pastes used in revascularization. J of Endod. 2014;40:845-8.\u003c/li\u003e\n \u003cli\u003eHargreaves KM, Diogenes A, Teixeira FB. Treatment options: biological basis of regenerative endodontic procedures. J of Endod.2013;39:S30-43.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eArslan H, Akcay M, Capar ID, Ertas H, Ok E, Uysal B. Efficacy of needle irrigation, EndoActivator, and photon-initiated photoacoustic streaming technique on removal of double and triple antibiotic pastes. J of Endod.2014;40:1439-42.\u003c/li\u003e\n \u003cli\u003eChou K, George R, Walsh LJ. Effectiveness of different intracanal irrigation techniques in removing intracanal paste medicaments. Aust Endod J. 2014;40:21-5.\u003c/li\u003e\n \u003cli\u003eBerkhoff JA, Chen PB, Teixeira FB, Diogenes A. Evaluation of triple antibiotic paste removal by different irrigation procedures. J of Endod. 2014;40:1172-7.\u003c/li\u003e\n \u003cli\u003eRuparel NB, Teixeira FB, Ferraz CC, Diogenes A. Direct effect of intracanal medicaments on survival of stem cells of the apical papilla. J of Endod. 2012;38:1372-5.\u003c/li\u003e\n \u003cli\u003eLabban N, Yassen GH, Windsor LJ, Platt JA. The direct cytotoxic effects of medicaments used in endodontic regeneration on human dental pulp cells. Dent \u0026nbsp;Trauma.2014;30:429-34.\u003c/li\u003e\n \u003cli\u003eArslan H, Capar ID, Saygili G, Uysal B, Gok T, Ertas H, et al. Efficacy of various irrigation protocols on the removal of triple antibiotic paste. Int Endod J.2014;47:594-9.\u003c/li\u003e\n \u003cli\u003eGuiotti FA, Kuga MC, Duarte MA, Sant\u0026apos;Anna AJ, Faria G. Effect of calcium hydroxide dressing on push-out bond strength of endodontic sealers to root canal dentin. Braz Oral Res. 2014;28.\u003c/li\u003e\n \u003cli\u003eGunes B, Yeter KY, Terlemez A, Seker B, Altay Y. Dentinal tubule penetration of endodontic sealers after nonthermal plasma treatment: A confocal laser scanning microscopy study. Micros Res and Techn. 2019;82:903-8.\u003c/li\u003e\n \u003cli\u003eAydın ZU, \u0026Ouml;zy\u0026uuml;rek T, Keskin B, Baran T. Effect of chitosan nanoparticle, QMix, and EDTA on TotalFill BC sealers\u0026apos; dentinal tubule penetration: a confocal laser scanning microscopy study. Odonto. 2019;107:64-71.\u003c/li\u003e\n \u003cli\u003eGharib SR, Tordik PA, Imamura GM, Baginski TA, Goodell GG. A confocal laser scanning microscope investigation of the epiphany obturation system. J of Endod.2007;33:957-61.\u003c/li\u003e\n \u003cli\u003eDeniz Sungur D, Aksel H, Purali N. Effect of a Low Surface Tension Vehicle on the Dentinal Tubule Penetration of Calcium Hydroxide and Triple Antibiotic Paste. J of Endod.2017;43:452-5.\u003c/li\u003e\n \u003cli\u003eMamootil K, Messer HH. Penetration of dentinal tubules by endodontic sealer cements in extracted teeth and in vivo. Int Endod J. 2007;40:873-81.\u003c/li\u003e\n \u003cli\u003eRussell A, Friedlander L, Chandler N. Sealer penetration and adaptation in root canals with the butterfly effect. Aust Endod J. 2018;44:225-34.\u003c/li\u003e\n \u003cli\u003eMachado MEL, Veintimilla Lozada VN, Carrillo Rengifo KJ, Guill\u0026eacute;n REG, Caballero-Flores H, Nabeshima CK. Confocal laser scanning microscopic analysis of the penetration of an epoxy resin-based sealer into dentinal tubules after calcium hydroxide dressing. Aust Endod J. 2021;47:480-6.\u003c/li\u003e\n \u003cli\u003eBitter K, Paris S, Mueller J, Neumann K, Kielbassa AM. Correlation of scanning electron and confocal laser scanning microscopic analyses for visualization of dentin/adhesive interfaces in the root canal. J of Adhes Dent. 2009;11:7-14.\u003c/li\u003e\n \u003cli\u003eUzunoglu-\u0026Ouml;zy\u0026uuml;rek E, Erdoğan \u0026Ouml;, Aktemur T\u0026uuml;rker S. Effect of Calcium Hydroxide Dressing on the Dentinal Tubule Penetration of 2 Different Root Canal Sealers: A Confocal Laser Scanning Microscopic Study. J of Endod. 2018;44:1018-23.\u003c/li\u003e\n \u003cli\u003eZorzin J, Wie\u0026szlig;ner J, Wie\u0026szlig;ner T, Lohbauer U, Petschelt A, Ebert J. Removal of Radioactively Marked Calcium Hydroxide from the Root Canal: Influence of Volume of Irrigation and Activation. J of Endod. 2016;42:637-40.\u003c/li\u003e\n \u003cli\u003eKok D, Rosa RA, Barreto MS, Busanello FH, Santini MF, Pereira JR, et al. Penetrability of AH plus and MTA fillapex after endodontic treatment and retreatment: a confocal laser scanning microscopy study. Micros Res And Techn. 2014;77:467-71.\u003c/li\u003e\n \u003cli\u003eMj\u0026ouml;r IA, Smith MR, Ferrari M, Mannocci F. The structure of dentine in the apical region of human teeth. Int Endod J. 2001;34:346-53.\u003c/li\u003e\n \u003cli\u003eCastagna F, Rizzon P, da Rosa RA, Santini MF, Barreto MS, Duarte MA, et al. Effect of passive ultrassonic instrumentation as a final irrigation protocol on debris and smear layer removal--a SEM analysis. Micros Res And Techn. 2013;76:496-502.\u003c/li\u003e\n \u003cli\u003eGokturk H, Bayram E, Bayram HM, Aslan T, Ustun Y. Effect of double antibiotic and calcium hydroxide pastes on dislodgement resistance of an epoxy resin-based and two calcium silicate-based root canal sealers. Clin Oral Investig. 2017;21:1277-82.\u003c/li\u003e\n \u003cli\u003eSarıyılmaz \u0026Ouml;, Uslu G, Sarıyılmaz E, Keskin NB. Evaluation of different irrigation activation techniques for the removal of various medicaments from a simulated internal resorption cavity: an in vitro study. Clin Oral Investig. 2024;28:491.\u003c/li\u003e\n \u003cli\u003eQuaresma SAL, Alves Dos Santos GN, Silva-Sousa AC, Camargo RV, Lopes-Olh\u0026ecirc; FC, Silva-Sousa YTC, et al. Physicochemical properties of calcium silicate cement based endodontic sealers. Journal of the mechanical behavior of biomedical materials. 2024;151:106400.\u003c/li\u003e\n \u003cli\u003eYan Y, Li Y, Chi Y, Ji M, Shen Y, Zou L. A comparative study of biological properties of three root canal sealers. Clin Oral Investig. 2023;28:11.\u003c/li\u003e\n \u003cli\u003eAshkar I, Sanz JL, Forner L, Ghilotti J, Melo M. A Literature Review of the Effect of Heat on the Physical-Chemical Properties of Calcium Silicate-Based Sealers. J of Endod.2024;50:1044-58.e5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"AH Plus, dentin penetration, confocal microscopy, intracanal medicament, root canal sealer","lastPublishedDoi":"10.21203/rs.3.rs-6368495/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6368495/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study investigated the effect of three intracanal medicaments on the penetration ability of three different root canal sealers using confocal laser scanning microscopy (CLSM).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e120 extracted single-rooted human teeth were used. The crowns were removed, and each canal was prepared. The teeth were divided into four groups (n=30): three medicament groups (calcium hydroxide (CH), triple antibiotic paste (TAP), and double antibiotic\u003cem\u003e \u003c/em\u003epaste [DAP]) and one control group. 0.1% Rhodamine B was incorporated. After three weeks, the medicaments were removed, and then canals were filled with one of the following sealers: \u0026nbsp;AHplus, MTAFillapex, and TotalFill (n=10). Fluorescein dye was added to the sealers. Horizontal sections (1 mm thick) were taken from the coronal, middle, and apical portions of each canal. Samples were then viewed under CLSM. Statistical analysis was performed using Kruskal Wallis and Mann-Whitney U tests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo statistically significant differences were found for the percentages of penetration of the sealers (p\u0026gt;.05). Regarding the maximum penetration values, there was a significant decrease for root canal sealers except for the Ah plus in the CH group (p\u0026lt;.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedicaments don’t significantly reduce the average penetration values of sealers.\u003c/p\u003e","manuscriptTitle":"Effect of intracanal medicament on dentin penetration ability of root canal sealers: A confocal study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 05:00:38","doi":"10.21203/rs.3.rs-6368495/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-09T08:20:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-05T10:32:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124039851058693169504081520667140150540","date":"2025-06-05T05:08:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-29T07:53:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119741241858095813788232795700856175897","date":"2025-05-29T07:31:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-13T11:18:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"252438265556569099359589721928606428077","date":"2025-04-29T10:49:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59337915231783384591157281287264929886","date":"2025-04-29T10:06:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-29T09:40:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-28T12:10:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-17T13:30:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-17T12:38:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-04-17T12:37:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0518dbd1-e00c-4faf-8238-ddaf1bbfbc05","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-28T16:04:10+00:00","versionOfRecord":{"articleIdentity":"rs-6368495","link":"https://doi.org/10.1186/s12903-025-06657-0","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2025-07-26 15:58:15","publishedOnDateReadable":"July 26th, 2025"},"versionCreatedAt":"2025-05-05 05:00:38","video":"","vorDoi":"10.1186/s12903-025-06657-0","vorDoiUrl":"https://doi.org/10.1186/s12903-025-06657-0","workflowStages":[]},"version":"v1","identity":"rs-6368495","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6368495","identity":"rs-6368495","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}