Bioceramics in Endodontics: Ideal for Single Cone Obturation and More!

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing the important properties of endodontic bioceramics and what you should know to make informed decisions. Our guest is Dr. Ali Nasseh, a clinical instructor and lecturer at Harvard School of Dental Medicine, specifically in the endodontic program. He is the current director of the endodontic microsurgery course at Harvard and also runs a private practice limited to endo. in downtown boston Dr. Nasseh is also the CEO and president of real world endo and endodontic education innovation and medical device company Dr. Nasseh it's a pleasure to have you on the show thanks for having me yeah so we really enjoyed your last podcast and this is a four-part series i'm talking to the audience now the first part was on irrigation the second one is the one we're doing now which is endodontic bioceramics we're going to be talking about in part three apicoectomies And then in part four, we'll be talking about rotation versus reciprocation. We've all heard those terms about our hand pieces and the instrument motion. So Dr. Nasseh is going to give us some insight into that as well. So for this podcast on bioceramics, we did do one already on bioceramics a while back on VivaLearning.com or your favorite podcast program, but he's got some updates. So can you tell us, Dr. Nasseh, about what ceramics are briefly and why they are useful? Sure. I mean, ceramics as a whole are... and kind of heat and corrosion resistant materials and that you know we're all familiar with with pottery and and all that stuff but bioceramics are those types of ceramics that are biocompatible so they can be placed inside the body and the body does not mount a serious inflammatory reaction to them so That's what's really the important part of bioceramics is the fact that they're biocompatible and they have a number of properties that are really optimized for use in the human body. And they've been kind of around since the 1960s and so. And they were used in orthopedic surgery and then slowly they made their way into dentistry. And in endodontics, the first bioceramics that came out was MTA in 1993. The studies that came out to show... how great MTA was doing was going to pave the way to make us understand that perhaps the next logical step would be to take these products, such as MTA, which had a very large particle size, break down the particle size, make it much smaller, and create a matrix that makes it much more flowable, and then be able to use that as an endodontic sealer. And that's essentially what ended up happening over time. Give us an example of... bioceramics are used in clinical endodontics, and what are some of the materials out there that we should be looking into? Essentially, right now, we have every possible application on a non-surgical side to the surgical side of endodontics using a bioceramic for that specific purpose. And there are a number of formulations. The original one that, as I mentioned, mta was a great product except that it had a number of limitations the mixing of it was very difficult because it was kind of powder and water it turned into mud and it kind of stained teeth over time because of the presence of bismuth oxide in 2008 a new uh bi -ceramic formulation was developed actually 2007 and 8 when finally came out and that was the end of sequence bc bi-ceramic line of products that was originally a sealer then i helped the manufacturer develop a putty for it and the putty was just the different consistency of the same base formulation the different viscosities of this line of materials you were essentially able to use these bi-ceramics for every possible application from sealer for pop capping a picture apexification, perforation repair on the non-surgical side and then on a surgical side for apicoectomies, for resorption repair, and also surgical resorption or perforation repair as well. And so these products all of a sudden became universal products in endodontics. And the reason for that, Phil, is because these bioceramics have properties that are... essentially designed for use in humans and they are so biocompatible that's one of the most biocompatible materials we have in dentistry but what's important also is that specific formulations of the bioceramics release calcium hydroxide which means that they are also antimicrobial because the pH of this product is high and we know These have a pH of about 12.8, and we know that a pH of 11 and above, most of the odontogenic microbes cannot survive. They're dimensionally stable. They don't shrink. They are not absorbable, which is a key thing, because if you are going to have a cement that's going to interface the body, you don't want this material to wash out. For the GPs out there that are listening to this podcast, are bioceramic sealers ideal for a single cone technique? For a GP that's doing tooth number eight, they do the instrumentation, they fit this beautiful master cone in, and they just flood the canal with this bioceramic sealer. Are they good to go? Yeah, I mean, provided that they've also done a great job of disinfecting the root canal ahead of time, right? I mean, we don't want to make it sound as though these bioceramics are a shortcut to sloppy work. On the obturation side. Yeah, on the obturation side. What they do is they simplify our obturation because originally we had these lateral and vertical condensation and thermoplasticizing the gut approach. It was very complicated. What bioceramics did is actually we kind of helped introduce that concept of hydraulic condensation, which is also referred to as single cone, which is the idea of, look, if you have one cone that's milled to the shape of the canal, all you're dealing with is just filling the gaps between the cone and the wall. You want to cement that. biocompatible and it chemically bonds to the dentin and also is dimensionally stable and non-absorbable to fill in the gaps. And that's basically where it took off. It's simplified observation. Yeah. So just, and I don't want to get too far off on a tangent here, but I know it's, it's a big thing, this single cone technique. So in the old days, just to give the audience an idea, when you used a single cone and then we use lateral condensation, we made lots of room with the spreader to add many accessory points. And the idea was to have a thin layer. of sealer and most of it was grossman cement which is a eugenol based sealer of course but now you're saying that using bioceramic sealer and that's the most prevalent application for the general dentist they're not going to be sealing perforations and they're not going to be doing resorption cases right they're going to be doing basic anterior premolar root canal therapy so using that single cone is there a technique that you advise so that they don't get voids in that bioceramic sealer with a single cone? That's why I don't like to refer to it as single cone. We call it now hydraulic condensation because in cases in which you have a very large oval canal, you do require to have more than one cone. But the difference here is that you don't need to use a condenser to condense the cone. cone itself is the condenser. You essentially are cementing one main cone in hydraulic condensation and then look around to see if you have additional spaces laterally to the main cone. And if you have an oval canal and you have a lot of space, you don't want too much pooling a sealer, not so much because there's a problem with the sealer but because you could potentially trap voids as you just mentioned. in those cases what you want to do is you want to put additional cones so that you can push the sealer a little bit more and all you have to do is use what we call now confirmation cones which is usually a 2504 and you can put in one or two most of the time one or two of those is all that it takes the vast majority of thinner canals end up really having room only for one cone but the reason we call it hydraulic condensation is because we don't want people to think that A single cone means that you are obligated to use only one cone. If you have an oval canal and you have additional room, put additional cones. It sounds so nice to do it that way compared to it. I mean, the thought of just gently sliding in these cones and letting the hydraulic pressure of the cone itself displace the bioceramic sealer into the voids and get the whole thing to be a monolithic obturation sounds like a dream to me. But anyway, I don't practice anymore, but boy, does that sound good. You know what's nice, Phil? What's that? I've been now doing every case since 2008 exclusively with this technique, and it's really satisfying now. in 2000 you know in 2021 to see these like 12 13 year cases come back absolutely with this hydraulic condensation completely stable and patients doing well you know because you know once you've been practicing as i have for the past 25 years in the same spot you see a lot of patients come back and you see what works and what doesn't work so so using this bioceramic sealer you're getting bonding to the dentin Do you do anything to the canal wall chemically? No, you don't need to do anything to it. It essentially bonds to hydroxyapatite chemically. So it is unlike resin composites that require a resin tack to go inside dental tubules. You don't need that. But studies have shown because of the high flow property, you actually see the bioceramic penetrate into the tubules too. So that gives you a better, actually a seal by plugging and closing that. But you do get a chemical bond to the hydroxyapatite. out of curiosity, do you know what the penetration in the market is with bioceramic sealer versus eugenol sealers? Where are we now with that? So it's a very different story today than it was in 2008. When I started talking about this stuff, nobody was using it, essentially. I did the very first case of it after its FDA approval in North America. So it is now... millions and millions of cases have been done. So in terms of exactly the percentage of market penetration, I can't tell you, but there are now a number of these compounds or these sealer cement materials out there in the market. And that's another key thing is as people are realizing the benefits of hydraulic condensation, the simplicity of it compared to the traditional techniques, people are using these more and more so many other companies are kind of coming in and introducing the bioceramic cements as well the key point that i can tell you about that is that it's important to understand that the term bioceramic right now is not properly regulated so anybody can call their bioceramic uh or whatever the cement they have or compound that they have formulation they have a bioceramic just because it contains one or two portions of a bioceramics, kind of like the wine industry back in the day. You know, you could put one grape of Cabernet grape in a bunch of cheap grape in a bottle and call it a Cabernet Sauvignon. That's why you need Appalachian Controle on your wines. It tells you where it came from and then you know. But that's a good point. But again, what is the name of the sealer that you recommend? The entire BC line of products of, you know, we've helped develop that for Brassler. And that's the BC Sealer and there's a BC Sealer High Flow. There is the RRM syringeable material. There is the putty material that I had a hand in myself, putty fast set. So it's all the same basic chemical formula that's patented. And there's just different viscosities of that material for different clinical applications. So it's technique based. That's a key component of the whole thing. So the only thing I think that listeners have to understand is that they have to read the MSDS sheets in all of the sealers of cement or bioceramics that they're dealing with to make sure the components are true bioceramics. And these are really complex compounds. Just the tiny little changes in formulation can change the solubility of the material in the long run and the bonding of the material in the long run. So there's a number of things that people have to consider. Very good information. Excellent information. podcast and it's good that you pointed out that it's unregulated because claims that are made on products if dentists aren't really following the details and the nuances they may purchase what they think is a bioceramic sealer that, like you said, has a very small percentage of bioceramic material in it. And it's essentially primarily some other kind of material. So we know Brassler makes quality products. They stand behind them. They do the R&D. They could feel confident by reaching out at least to get some more information on this stuff from Brassler or other companies that you know and respect in the industry. Thanks very much, Dr. Nasseh. We'll see you on the next podcast. Thank you so much.