UNIVERSIDADE ESTADUAL PAULISTA

“JÚLIO DE MESQUITA FILHO”

Instituto de Ciência e Tecnologia

Campus de São José dos Campos

ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2024.e4060

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in

any medium, provided the original work is properly cited.

Inﬂuence of root canal sealer composition on postoperative pain

after endodontic treatment of permanent teeth: a systematic

review and meta-analyses

Inﬂuência da composição do cimento endodôntico na dor pós-operatória de dentes permanentes tratados

endodonticamente: uma revisão sistemática e meta-análise

Vânia Gomes MORAES1 , Sandra Regina Santos MEYFARTH2 , Guido Artemio MARAÑÓN-VÁSQUEZ3 ,

Lívia Azeredo Alves ANTUNES4 , Leonardo Santos ANTUNES4 

1 - Universidade Federal Fluminense, Faculdade de Odontologia. Nova Friburgo, RJ, Brazil.

2 - Universidade Federal Fluminense, Faculdade de Odontologia. Niterói, RJ, Brazil.

3 - Universidade Federal do Rio de Janeiro, Faculdade de Odontologia. Rio de Janeiro, RJ, Brazil.

4 - Universidade Federal Fluminense, Faculdade de Odontologia de Nova Friburgo, Departamento de Formação Especíca. Nova

Friburgo, RJ, Brazil.

How to cite: Moraes VG, Meyfarth SRS, Marañón Vásquez GA, Antunes LAA, Antunes LS. Inuence of root canal sealer composition

on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses. Braz Dent Sci. 2024;

27(1):e4060. https://doi.org/10.4322/bds.2024.e4060

ABSTRACT

Postoperative pain is a frequent complication after root canal treatment. Its management is an important aspect of

endodontic practice. Some treatment-related parameters were associated with the development of postoperative

pain, including the sealer composition and extrusion. Objective: This systematic review aimed to answer the

clinical question: Do root canal sealers composition inuence postoperative pain after endodontic treatment of

permanent teeth? Material and Methods: Electronic searches were conducted in PubMed, Scopus, Web of Science,

Cochrane, LILACS, and grey literature databases until September 2021. The studies were qualitatively assessed

using the RoB2 tool (Cochrane) and the certainty of evidence (GRADE). Sensitivity and pooled estimates were

calculated using a random-effects model. Twelve articles were included. Results: The risk of bias was high in

one study, low in nine, and two had some concerns. Qualitative analyses showed no inuence of sealer extrusion

on postoperative pain. Meta-analyses showed no signicant difference in postoperative pain with moderate to

very low levels of certainty between AH Plus and calcium silicate-based sealers, in a 95% condence interval.

Analysis between AH Plus, Zinc Oxide and Eugenol (ZOE), and calcium hydroxide (Ca(OH)2)-based sealers

were not performed due to heterogeneity and lack of data. Conclusion: Literature showed contrasting results

in postoperative pain between AH Plus and ZOE-based sealers, with low to moderate certainty of evidence.

Regarding Ca(OH)2-based sealers, a single study with a low level of certainty concluded that AH Plus presented

less postoperative pain than Apexit Plus. Therefore, further studies are needed to assess the inuence of these

sealers on postoperative pain. Evidence showed no difference in postoperative pain between AH Plus and calcium

silicate-based sealers. Sealer extrusion is a variable that requires further studies.

KEYWORDS

Postoperative pain; Root canal treatment; Sealer composition; Sealer extrusion; Systematic review.

RESUMO

A dor pós-operatória é uma complicação frequente após o tratamento endodôntico. O seu manejo é um

importante aspecto na prática endodôntica. Algumas variáveis relacionados ao tratamento foram associados

com o desenvolvimento da dor pós-operatória, incluindo a composição e extrusão dos cimentos endodônticos.

Objetivo: Esta revisão sistemática objetivou responder a seguinte pergunta clínica: A composição dos cimentos

endodônticos podem inuenciar a dor pós-operatória de dentes permanentes tratados endodonticamente?

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

INTRODUCTION

Postoperative pain is a frequent complication

after root canal treatment and such condition may

have an impact on patients quality of life [1].

Generally, it ranges from mild to moderate

and occurs even after optimal procedures are

performed [2]. However, pain control remains a

key issue in endodontic treatment [3].

Pain is multifactorial in nature [4] and

can be induced by mechanical, chemical, or

microbiological injuries to the periodontal

tissues [5]. Endodontic sealers may affect the

periradicular tissues either by direct contact or by

percolating components that are released through

the root canal systems [6] which may trigger

an inammatory response increasing the risk of

postoperative pain [7]. Such sealers are developed

to be inside the root canal system. However,

unintentional extrusion may occur [8] thus

causing symptoms such as pain, hyperesthesia,

and paresthesia [9]. These symptoms may vary

in intensity depending on the amount of extruded

sealer [10].

A wide variety of root canal sealers are

currently available in the market. Of these,

Zinc Oxide and Eugenol (ZOE)-based, calcium

hydroxide (Ca(OH)2)-based, glass ionomer,

mineral trioxide aggregate, and resin-based sealers

are commonly used. Additionally, bioceramic

sealers have recently been launched [6,11].

Histological ndings indicate that components

percolated from the root canal sealers may induce

local inammatory effects [12] and its intensity is

related to the sealer composition [6]. Dysregulated

cytokine production during inflammatory

processes is a potential contributor to the

development of inflammatory diseases [13].

Interleukin-6 (IL-6) and (IL-8) release have been

reported to play an important role in root canal

sealer-induced periapical inammation [13,14].

Two systematic reviews [15,16] evaluated

the risk and intensity of postoperative pain with

calcium silicate and epoxy resin-based sealers,

but not with other types of sealers. Additionally,

both studies presented contrasting results.

Sponchiado et al. [15] showed no statistical

difference between the composition and pain

between these two sealers. Mekhdieva et al. [16]

concluded that calcium silicate-based sealers

were associated with signicantly lower pain than

epoxy resin-based sealers.

Therefore, this systematic review aimed

to investigate current evidence regarding the

inuence of other types of sealers composition

on postoperative pain after endodontic treatment.

The clinical question was designed according

to the Population, Intervention, Comparator,

Outcome, and Study (PICOS) and should answer

the following clinical question: Do root canal

sealer composition inuence postoperative pain

after endodontic treatment of permanent teeth?

MATERIAL AND METHODS

This systematic review and meta-analysis was

conducted according to the Preferred Reporting

Material e Métodos: Buscas eletrônicas foram realizadas nas bases de dados no PubMed, Scopus, Web of Science,

Cochrane, LILACS, e literatura cinzenta até setembro de 2021. Os estudos foram avaliados qualitativamente usando

a ferramenta RoB2 (Cochrane) e a certeza de evidência (GRADE). A sensibilidade e as estimativas agrupadas

foram calculadas usando um modelo de efeitos aleatórios. Doze artigos foram incluídos. Resultados: O risco de

viés foi alto em um estudo, baixo em nove e dois tiveram algumas preocupações. A análise qualitativa mostrou

que não há inuência da extrusão do cimento na dor pós-operatória. A meta-análise mostrou que não houve

diferença estatisticamente signicante na dor pós-operatória entre o AH Plus e os cimentos a base de silicato de

cálcio com moderada a muito baixa certeza de evdência. Análises entre os cimentos AH Plus, óxido de zinco e

eugenol (OZE) e hidróxido de cálcio não foram realizados devido a heterogeneidade e falta de dados. Conclusão:

A literatura sugere resultados contrastantes com relação a dor pós-operatória e entre os cimentos AH Plus e OZE,

com baixa a moderada certeza de evidência. Já os cimentos a base de hidróxido de cálcio, um único estudo com

baixa certeza de evidência concluiu que o AH Plus apresentou menos dor pós tratamento endodôntico do que

o Apexit Plus. Portanto,mais estudos são necessários para avaliar a inuência desses tipos de cimentos na dor

pós-operatória. Com relação ao cimento AH Plus e os cimentos a base de silicato de cálcio não houve diferença

estatística entre eles e a dor. A extrusão dos cimentos é uma variável que requer mais estudos.

PALAVRAS-CHAVE

Dor pós-operatória; Tratamento endodôntico; Composição dos cimentos; Extrusão dos cimentos; Revisão sistemática.

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Items for Systematic Reviews and Meta-analysis

(PRISMA) statement [17] and was registered in

the PROSPERO database (CRD42020211297).

Eligibility criteria

The inclusion criteria was outlined according

to the Population, Interventions, Comparisons,

Outcomes, and Studies. The articles should

answer the following PICOS, as follow:

(P) Population included patients undergoing

nonsurgical root canal treatment in

permanent teeth;

(I) Intervention included root canal lling with

AH Plus sealer with or without extrusion;

with other types of sealer with or without

extrusion;

(O) Outcome included postoperative pain after

root canal treatment;

(S) Study design included randomized controlled

trials (RCTs).

Exclusion criteria

Duplicated articles, pilot studies, literature

reviews, editorial letters, book chapters, theses

and guidelines were excluded.

Search strategy and study selection

An electronic search was conducted to

identify relevant articles. No restrictions were

imposed on the dates. Studies published in

English, Portuguese and Spanish were included.

The following databases were searched until

September 29, 2021: PubMed, Scopus, Web

of Science, Cochrane, LILACS, and OpenGrey.

In addition, MeSH terms, synonyms, and free

terms were used and combined to refine the

search results, as presented in Table I. Experts

were contacted to identify related unpublished

and ongoing studies. The records were exported

to Mendeley (Mendeley Ltd., UK, England);

duplicates were considered only once.

Before analyzing the selected abstracts, a

Kappa test was conducted to evaluate agreement

among evaluators (10% of the publications

were randomly selected). Subsequently, their

classifications were compared, resulting in a

kappa statistic of 0.90. All potentially relevant

publications were selected by reading the titles

and abstracts by two independent reviewers

(VM and SM). Any differences between them

were resolved by consensus with the third

author (LSA). Studies without abstracts were

also assessed for inclusion. Subsequently, the

full texts of all potentially eligible studies were

accessed; inclusion and exclusion criteria were

then applied. Any other disagreements were

resolved by consensus with the senior reviewer

(LSA). Additionally, the reference lists of the

included studies were manually searched to

retrieve all eligible articles.

Data extraction

Data were extracted by two independent

authors (VM and SM) and organized as follows:

1. First author, year of publication;

2. Sample (sample size, gender, tooth type,

tooth diagnosis);

3. Endodontic treatment (irrigation,

instrumentation, number of sessions,

obturation technique, type of sealer);

4. Preoperative symptoms;

5. Pain assessment (pain scale, period in hours,

and analgesic intake);

6. Postoperative symptoms;

7. Results.

Risk of bias

The RoB2 tool was used for assessing the

risk of bias (RoB) of the selected RCTs [18].

Two authors (LSG and SM) independently

assessed the RoB of the included studies in a

duplicate manner. Disagreements were resolved

by consensus with the senior reviewer (LSA).

If relevant data were missing, the authors were

contacted. The sources of bias assessed were

the randomization process, deviations from the

intended intervention, missing outcome data,

measurement of the outcome, and selection of

the reported result. Each domain was classied

as having low (+), high (x), or some concerns (-)

RoB. A study was considered to have an overall

high RoB if judged to be at high RoB in at least

one domain or judged to have “some concerns”

for multiple domains in a way that substantially

lowers confidence in the result. A study was

considered to have an overall some concerns RoB

if judged to be at “some concerns” in at least one

domain. Finally, a study was considered to have

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

an overall low RoB if judged to be at low RoB for

all domains [18].

Meta-analysis

A meta-analysis was performed to combine

comparable results using subgroup analysis.

Extraction data of the mean and the standard

deviation with 95% confidence interval (CI)

related to the post-operative pain between the

types of sealer groups in the time intervals of

6, 12, 24, 48, and 72 hours were performed.

A random effects model was used in the meta-

analysis. The mean differences between the sealer

groups were determined using inverse variance

meta-analysis. I2 was used to assess the statistical

heterogeneity between studies, where values of

25%, 50%, and 75% indicated low, medium,

and high heterogeneity, respectively [19].

Meta-analysis and forest plots were performed

using the RevMan 5.4. Sensitivity analyses

using different methods of data imputation and

subgroup analyses were also planned.

Evidence synthesis (GRADE)

The Grading of Recommendations

Assessment, Development, and Evaluation

(GRADE) system for classifying the certainty of

the evidence was used to ensure the accuracy

of data analysis. GRADE Pro GDT software

(http://gdt.guidelinedevelopment.org) was

used to summarize the results. Certainty is

downgraded owing to RoB, inconsistency,

Table I - Electronic Databases and Search Strategy

Pub Med

n=463

(((((((((((((root canal therapy[MeSH Terms]) OR (root canal therapy[Title/Abstract])) OR (teeth, endodontically

treated[MeSH Terms])) OR (teeth, endodontically treated[Title/Abstract])) OR (endodontically-treated tooth[MeSH

Terms])) OR (endodontically-treated tooth[Title/Abstract])) OR (root canal preparation[MeSH Terms])) OR (root canal

preparation[Title/Abstract])) OR (tooth root therapy[Title/Abstract])) OR (endodontic therapy[Title/Abstract])) OR

(endodontic treatment[Title/Abstract])) OR (root canal treatment[Title/Abstract])) AND ((((((((((((((((((((root canal ﬁlling

materials[MeSH Terms]) OR (root canal ﬁlling materials[Title/Abstract])) OR (endodontic obturation[MeSH Terms]))

OR (endodontic obturation[Title/Abstract])) OR (root canal obturation[MeSH Terms])) OR (root canal obturation[Title/

Abstract])) OR (root canal obturations[MeSH Terms])) OR (root canal obturations[Title/Abstract])) OR (Root Canal

Sealants[MeSH Terms])) OR (Root Canal Sealants[Title/Abstract])) OR (root canal cement[Title/Abstract])) OR (root

canal ﬁlling[Title/Abstract])) OR (endodontic cement[Title/Abstract])) OR (endodontic sealer[Title/Abstract])) OR (root

canal sealer[Title/Abstract])) OR (root canal cement extrusion[Title/Abstract])) OR (root canal ﬁlling extrusion[Title/

Abstract])) OR (root canal sealer extrusion[Title/Abstract])) OR (endodontic cement extrusion[Title/Abstract])) OR

(endodontic sealer extrusion[Title/Abstract]))) AND (((((((((((((((((pain[MeSH Terms]) OR (pain[Title/Abstract])) OR

(pain, postoperative[MeSH Terms])) OR (pain, postoperative[Title/Abstract])) OR (postoperative pain[MeSH Terms])) OR

(postoperative pain[Title/Abstract])) OR (hyperemia[MeSH Terms])) OR (hyperemia[Title/Abstract])) OR (toothache[MeSH

Terms])) OR (toothache[Title/Abstract])) OR (odontalgia[MeSH Terms])) OR (odontalgia[Title/Abstract])) OR (edema[Title/

Abstract])) OR (hyperesthesia[Title/Abstract])) OR (heat[Title/Abstract])) OR (swelling[Title/Abstract])) OR (touch

pain[Title/Abstract]))

Scopus

n=981

(TITLE-ABS-KEY (root AND canal AND therapy) OR TITLE-ABS-KEY (teeth, AND endodontically AND treated) OR TITLE-

ABS-KEY (endodontically-treated AND tooth) OR TITLE-ABS-KEY (root AND canal AND preparation) OR TITLE-ABS-KEY

(tooth AND root AND therapy) OR TITLE-ABS-KEY (endodontic AND therapy) OR TITLE-ABS-KEY (endodontic AND

treatment) OR TITLE-ABS-KEY (root AND canal AND treatment) AND (TITLE-ABS-KEY (root AND canal AND ﬁlling AND

materials) OR TITLE-ABS-KEY (endodontic AND obturation) OR TITLE-ABS-KEY (root AND canal AND obturation) OR

TITLE-ABS-KEY (root AND canal AND obturations) OR TITLE-ABS-KEY (root AND canal AND sealants) OR TITLE-ABS-KEY

(root AND canal AND cement) OR TITLE-ABS-KEY (root AND canal AND ﬁlling) OR TITLE-ABS-KEY (endodontic AND

cement) OR TITLE-ABS-KEY (endodontic AND sealer) OR TITLE-ABS-KEY (root AND canal AND sealer) OR TITLE-ABS-

KEY (root AND canal AND cement AND extrusion) OR TITLE-ABS-KEY (root AND canal AND ﬁlling AND extrusion) OR

TITLE-ABS-KEY (root AND canal AND sealer AND extrusion) OR TITLE-ABS-KEY (endodontic AND cement AND extrusion)

OR TITLE-ABS-KEY (endodontic AND sealer AND extrusion) AND (TITLE-ABS-KEY (pain) OR TITLE-ABS-KEY (pain,

AND postoperative) OR TITLE-ABS-KEY (postoperative AND pain) OR TITLE-ABS-KEY (hyperemia) OR TITLE-ABS-KEY

(toothache) OR TITLE-ABS-KEY (odontalgia) OR TITLE-ABS-KEY (edema) OR TITLE-ABS-KEY (hyperesthesia) OR TITLE-

ABS-KEY (heat) OR TITLE-ABS-KEY (swelling) OR TITLE-ABS-KEY (touch AND pain)

WoS

n=454

pain OR pain, postoperative OR postoperative pain OR hyperemia OR toothache OR odontalgia OR edema OR

hyperesthesia OR heat OR swelling OR touch pain

Cochrane

Reviews

n=304

root canal therapy OR teeth, endodontically treated OR endodontically-treated tooth OR root canal preparation OR tooth

root therapy OR endodontic therapy OR endodontic treatment OR root canal treatment in Title Abstract Keyword AND

root canal ﬁlling materials OR endodontic obturation OR root canal obturation OR root canal obturations OR Root Canal

Sealants OR root canal cement OR root canal ﬁlling OR endodontic cement OR endodontic sealer OR root canal sealer

OR root canal cement extrusion OR root canal ﬁlling extrusion OR root canal sealer extrusion OR endodontic cement

extrusion OR endodontic sealer extrusion in Title Abstract Keyword AND pain OR pain, postoperative OR postoperative

pain OR hyperemia OR toothache OR odontalgia OR edema OR hyperesthesia OR heat OR swelling OR touch pain in Title

Abstract Keyword - (Word variations have been searched)

Lilacs/BVS

n=4

tw:((tw:(root canal therapy OR tooth, nonvital)) AND (tw:(root canal ﬁlling materials OR root canal obturation)) AND

(tw:(acute pain OR pain, postoperative OR toothache))) AND (db:(“LILACS”))

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

indirectness, imprecision, and publication

bias [20,21]. The level of certainty among the

identied evidence can be characterized from

very low to high [21].

RESULTS

Search and Study selection

An electronic search identied 2,363 studies

by searching the databases: 463 from MEDLINE

(PubMed), 454 from Web of Science, 981 from

Scopus, 304 from Cochrane Reviews, 4 from

Lilacs (Virtual Health Library) and 157 registers

in Clinical Trials. Of these, 288 were duplicated

and removed using an automated tool. After

screening titles and abstracts, 1,931 articles were

excluded since they did not meet the inclusion

criteria. Thirty-two articles were potentially

eligible; their texts were then read in full. Three

studies were included from citation search.

Twelve studies were included in the systematic

review (Figure 1). Appendix 1 shows the studies

excluded from the full-text analysis.

Risk of bias

Nine studies had low RoB [22-30], one was

considered to have a high RoB due to bias in the

randomization process and deviations from the

intended interventions [31], while two [32,33]

were judged to be at some concerns due to bias

arising from the randomization process. Details

regarding downgrading are provided in Figure 2.

The most frequent domain causing downgrading

was bias due to the randomization process and

deviations from the intended intervention.

No study had attrition bias due to missing

outcome data or selection of reported results.

Qualitative analysis

Tables II and III present the data extractions

of the selected studies.

Of the 12 studies, two evaluated sealer

extrusion and postoperative pain [27,30], nine

sealer composition and pain [22-26], and one

evaluated both, sealer composition and extrusion

on postoperative pain [28].

Figure 1 - PRISMA ﬂowchart of the manuscripts screened through the review process.

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Table II - Evidence table summarizing the characteristics of the included studies

Author

Sample Endodontic treatment Pre

operative symptom

Sam

ple size Gender Tooth diagnosis Tooth type Irrigation solu-

tion Instrumentation N° sessions Obturation tech-

nique Sealers

Ambika and Satish [26]90 NI NI NI NI NI 1NI Endosequence

BC;

MTA; AH Plus

Pazetal. [31] 30 NI pulpitis, pulp

necrosis, and

retreatment

NI 2.5% NaOCl ProTaper Next 1 or 2 Cold lateral

condensation

BioRoot RCS; AH

Plus

Graunaiteetal. [29] 61 25 males 36

females

Asymptomatic

apical

periodontitis

Single /multi-

rooted

2% NaOCl ProTaper Gold 1Warm vertical

condensation

AH Plus; Total

Fill BC

Atavetal. [28] 160 67 males 89

females

Pulp necrosis and

vital teeth Single /multi-

rooted

2.5% NaOCl One Shape 1

Heroﬁll™ Soft-

Core obturator

iRoot SP;

Innovative

BioCeramix; AH

Plus

Yes

Fonsecaetal. [27] 64 26 males

38 females

Pulp necrosis Single rooted 2.5% NaOCl Reciproc VDW 1Single cone AH Plus; Sealer

Plus BC

Ferreiraetal. [25] 60 19 males

41 females Pulp necrosis Single /multi-

rooted

2.5% NaOCl Wave One Gold 2

Single cone

and vertical

compaction

AH Plus; EndoFill

MTA Fillapex No

Gudlavalletietal. [33]99 45 males

54 females

Chronic

irreversible

pulpitis Multi-rooted 3% NaOCl Protaper

Universal 1 Cold lateral

condensation

Tubli-Seal EWT;

Apexit Plus; AH

Plus

Yes

Cunhaetal. [23] 69 33 males

27 females

pulpitis and pulp

necrosis Multi-rooted 2.5% NaOCl Protaper Next 2 to 4 Single cone +

accessory cones

AH Plus; Sealer

26 Yes

Tanetal. [22] 171 76 males

87 females

Pulp necrosis

and vital teeth

Single /multi-

rooted

1,25% NaOCl Rotatory ﬁles 1 or

Single cone and

Warm vertical

Compaction

AH Plus; TotalFill

BC Yes

Shimetal. [32] 108 36 males

31 females NI Single /multi-

rooted

2.5% NaOCl Protaper Next 2 to 4

Single cone and

Continuous wave AH Plus; Endoseal

MTA Yes

Drumondetal. [30] 330 36 males

31 females

Asymptomatic

irreversible

pulpitis

Multi-rooted 2% chlorhexidine

gel Wave One Gold 1

Single cone and

Warm vertical

Compaction

AH Plus; BC

Sealer; Bio-C

Sealer

Aslanetal. [24] 96 34 males

females

Asymptomatic

irreversible

pulpitis

Multi-rooted 5% NaOCl Reciproc VDW 1Single cone AH Plus;

Endoseal MTA;

Endosequence BC

NI = not informed.

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Table III - Summary of the parameters and results collected for each study

Author

Pain assessment

Results

Pain scale Period

(hours)

Analgesic

intake

Postoperative

symptoms

Ambika and Satish [26] VAS 24, 72, 120,

168 NI Pain

None of the patients reported postoperative pain after 3rd

day. No patient reported severe pain at any time interval.

Postoperative pain during the 1h and 1, 3 days intervals was

signiﬁcantly diﬀerent (p <0.05) between groups.

Pazetal. [31] Modiﬁed

VAS

24, 48, 72,

96, 120, 144,

168

Ibuprofen

600 mg Pain

Bioceramic referred postoperative pain more frequently than

resin sealer. There were statistically signiﬁcant diﬀerences in

post-operative pain intensity only between day 1 and day 6 and

between day 1 and day 7 (p = 0.002) respectively.

Graunaiteetal. [29] VAS 24, 48, 72,

168

Nonsteroid

analgesics Pain

There was no statistically signiﬁcant diﬀerence between the

tested root canal sealers regarding postoperative pain at any

time points assessed (P > .05).

Atavetal. [28] Huskisson

VAS 6, 12, 24, 72 Ibuprofen

200 mg Pain

There was no signiﬁcant diﬀerence between groups in the

incidence of postoperative pain; however, iRoot SP sealer was

associated with less analgesic intake compared to AH Plus

sealer. No correlation between sealer extrusion-pain intensity

and analgesic intake.

Fonsecaetal. [27] VAS 24, 48, 72 Ibuprofen

600 mg Pain

No statistically signiﬁcant diﬀerence between the groups with

regard to pain level and intake of analgesics (p > 0.05). Sealer

Plus BC presented a statistically signiﬁcant more extrusion

(59.37%) than AH Plus (28.12%). Sealer extrusion was not

associated with pain.

Cunhaetal. [23] NI aNI Pain

No eﬀect of sealer composition was observed. Apical repair

incidences and asymptomatic teeth were, respectively, 90.5 and

89.3, 96.8 and 90.0% during 1 and 2 years of follow-up.

Ferreiraetal. [25] Descriptive 24, 48, 168 Ibuprofen

600 mg Pain

No signiﬁcant diﬀerences were detected among the groups in

terms of either incidence or intensity of postoperative pain, or

need for analgesic intake, at any time point (p>0.05).

Gudlavalletietal. [33] VAS 8, 24, 48 Ibuprofen

200 mg Pain There was statistically signiﬁcant diﬀerence seen in all three

groups (p=0.0001) at all the time points (8h, 24h and 48h).

Tanetal. [22] Likert 24, 72, 168 IbuprofencPain

There was no signiﬁcant diﬀerence in pain experience between

teeth ﬁlled using AH Plus or TotalFill BC Sealer 1, 3, and 7 days

after obturation.

Shimetal. [32] VAS

24, 48, 72,

96, 120, 144,

168

NI Pain Endoseal MTA and AH Plus had equivalent eﬀects on

postoperative pain incidence and intensity.

Drumondetal. [30] Modiﬁed

NRS

6, 12, 24, 48,

168

Acetaminophen

500 mg Pain

The occurrence of unintentional apical extrusion of calcium

silicate–based root canal sealers present similar postoperative pain

results compared with resin-based sealers with low-intensity pain.

Aslanetal. [24] VAS 6, 12, 24, 48 Ibuprofen

400 mg Pain

There were no signiﬁcant diﬀerences among the groups in terms

of postoperative pain at any time points assessed (P>0.05) nor

for analgesic intake of patients among the groups (P>0.05).

NI = not informed; NRS = numeric rating scale; VAS = visual analogue scale; aperiod of 1 and 2 years; cmilligrams not informed.

Figure 2 - Quality assessment of selected studies (the Cochrane Collaboration tool for assessing risk of bias – RoB2).

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

One study used single-rooted teeth [27],

four multi-rooted [23,24,30,33], ve multi- and

single-rooted teeth [22,25,28,29,32], and two did

not inform the type of teeth [26,31]. The average

number of teeth per study was 115.5, with a

minimum of 30 and a maximum of 330.

Concerning the number of sessions,

seven studies were carried out in a single

session [24,26-30,33], and ve studies in multiple

sessions [22,23,25,31,32].

Postoperative pain was assessed in all

studies. Six studies evaluated pain using a visual

analogue scale (VAS) [24,26,27,29,32,33], one

using a modified VAS form [31], one using

a descriptive scale [25], one using a Likert

scale [22], one using a modied visual rating

scale [30], one not using a binary scale (pain

present or absent) [23], and one using the

Huskisson VAS form [28].

Six studies did not report analgesic

intake [23,26,30-33]. Only two studies [24,28]

assessed NSAID intake at 6 and 12 h, showing a

higher intake in the rst 6 h in both studies. At both

time intervals, there was no statistically signicant

difference in analgesic intake between the groups.

Six studies [22,24,25,27-29] assessed NSAID intake

at 24 h, with no statistical difference in any of the

groups. At 48 h, two studies [24,25] reported that

very few patients took analgesics; however, there

was no difference among the groups. The same

trend was observed at 72 h [22,28].

Regarding sealer composition, seven

studies [22-25,28,29,32] compared pain intensity

between AH Plus (Dentsply Maillefer, Konstanz,

Germany) and calcium silicate-based sealers. They

found no statistical difference between the groups

regarding the level of pain. On the other hand, two

studies found statistically signicant differences

in postoperative pain intensity between the

groups [26,31]. Paz et al. [31] reported that the

AH Plus group reported postoperative pain less

frequently than the Bioroot group (Septodont,

Saint Maur-des-Fosses, France). However,

Ambika and Satish [26] reported that AH Plus

presented with more postoperative pain than

MTA Fillapex (Angelus, Londrina, Brazil) and

Endo Sequence BC (Brasseler, Savannah, GA,

USA) at all time intervals.

Two studies compared pain intensity

between AH Plus and ZOE-based sealers [25,33]

Ferreira et al. [25] found no statistical difference

between AH Plus and Endofill (Dentisply,

Petrópolis, Brazil). In contrast, Gudlavalleti et al.

[33] concluded that AH Plus resulted in less

postoperative pain than Tubliseal (SybronEndo,

Glendora, CA, USA).

A single study comparing pain intensity

between AH Plus and Ca (OH)2-based

sealers [33] concluded that AH Plus presented

less postoperative pain than Apexit Plus (Ivoclar,

Vivadent, De Trey, Germany).

Studies that evaluated sealer extrusion

and postoperative pain [27,28,30] showed

no association between extrusion and pain

occurrence. Atav et al. [28] concluded that AH

Plus had more extrusion than iRoot SP (Innovative

BioCeramix Inc., Canada). Fonseca et al. [27]

found that Sealer Plus BC (MK Life, Porto Alegre,

RS, Brazil) had a signicantly higher incidence

of extrusion than AH Plus. Drumond et al. [30]

found that unintentional apical extrusion of AH

Plus presented with postoperative pain similar to

those of EndoSequence BC (Brasseler, Savannah,

GA, USA) and Bio-C (Angelus, Londrina, PA,

Brazil).

Quantitative analysis

Homogeneous data from the included

studies were compared using meta-analysis.

Two eligible studies were excluded [23,24]. Data

of one study [24] could not be extracted. In this

case, the corresponding author was contacted by

email; however, missing data were not provided.

Another study [23] reported the total number

of patients who developed postoperative pain as

present or absent, but did not inform the sealers

group.

The meta-analyses of studies with continuous

data [27-30] demonstrated that the comparison

between the level of pain and AH Plus vs. calcium

silicate-based sealers showed no significant

difference between groups at all time intervals

(p > 0.05) (Figure 3).

Regarding the meta-analyses of studies with

binary data [22,25,26], there was no statistically

signicant difference in pain intensity in any of

the reported periods. Subgroup tests showed

that the size effect between AH Plus and calcium

silicate-based sealers was the same at all time

intervals (p > 0.05) (Figure 4).

Studies that compared pain intensity

between AH Plus and ZOE-based sealers [25,33],

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Figure 3 - Forest plots of postoperative pain between AH Plus vs Calcium silicate-based sealers groups (6, 12, 24, 48, and 72 hours).

Figure 4 - Forest plots of the relative risk (RR) for postoperative pain between AH Plus vs Calcium silicate-based sealers groups (24, 48, and

72 hours).

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

the meta-analysis could not be performed due to

outcome variability.

A meta-analysis to assess the intensity of

pain between AH Plus and Ca (OH)2-based

sealers could not be performed because only one

study presented data [33]. Atav et al. [28] also

evaluated devital teeth with AH Plus and iRoot

SP; Paz et al. [31] assessed teeth with AH Plus

and two different obturation techniques; and

Shim et al. [32] evaluated AH Plus and Endoseal

MTA in multirooted teeth. Therefore, additional

meta-analyses were performed, including those

data, and no statistical differences were observed

(Appendices 2 and 3).

Evidence synthesis (GRADE)

The overall certainty varied from moderate

to very low for all the syntheses. All analyses were

downgraded due to imprecision (low number

of participants) and RoB (Table IV). For each

outcome, analysis of the certainty of evidence

was performed based on the time intervals

investigated. For imprecision (pain intensity), a

threshold of 1 point on the 10-point VAS [34],

as well as a minimum sample of 400 was used.

DISCUSSION

The literature suggests several etiological

factors of postoperative pain, including sealer

extrusion [3] and composition [6] This systematic

review aimed to investigate current evidence

regarding the influence of various types of

sealer composition on postoperative pain after

endodontic treatment. In this review AH Plus

sealer (Dentsply, De Trey, Konstanz, Germany)

was chosen as the control group. AH-Plus is

a resin-based sealer and represents the gold

standard in clinical practice and in

in vitro

studies

and is the reference material for other types of

sealers [24].

As root canal sealers may frequently

come into contact with perirradicular tissues,

biocompatibility is of paramount importance [35].

Some

in vitro

studies have reported conicting

results regarding biocompatibility [36,37].

Nonetheless, these ndings should be cautiously

interpreted, as the results of

in vitro

toxicity tests

may not correlate with

in vivo

response [35].

The results of our meta-analyses between AH Plus

and calcium silicate-based sealers conrmed the

results of most of the selected studies; there was

no statistical difference in pain intensity at any

time interval. This can be attributed to the fact

that, except for paraformaldehyde-containing

materials, most contemporary root canal sealers

are either biocompatible or show cytotoxicity only

prior to setting [38]. This may not be sufcient

to induce an intense inflammatory reaction,

which may justify the non-difference between the

groups in the selected studies. Another scenario,

may suggest that both AH Plus and calcium

silicate-based sealers were adequate.

The individual results of the eligible studies

showed no association between sealer extrusion

and the occurrence or intensity of postoperative

pain [27,28,30]. This phenomenon might be due

to the small surface of contact between the lling

material and the periapical tissue. In all selected

studies, the authors reported that there was no

signicant amount of extruded sealer. Cases of

gross overlling are generally associated with

clinical symptoms and sealer composition [39].

Another issue that must be pointed out is that

in the methodology of the selected articles that

assessed post-operative pain and sealer extrusion,

there was no control group (no sealer extrusion).

Therefore, this design cannot determine whether

any deviation in the results from the treatment

group is a direct result of the variable. Thus,

sealer extrusion is a variable that requires further

clinical evaluation.

The intake of NSAID after endodontic

treatment significantly reduces postoperative

pain [40]. The studies included in this

systematic review reported that analgesics/anti-

inflammatory consumption was low, with no

statistical difference between groups with regards

to pain level. The lack of signicant difference in

analgesic intake may be indicative of the fact that

despite the occurrence of postoperative pain, it

may not be clinically relevant. The endodontic

treatment includes a complex of procedures such

as chemomechanical debridement and obturation.

Pain after root canal treatment is expected and

it might also be referred to sensitivity caused by

pressure of the clamp, injection of local anesthetic

or by instrumentation and chemical irrigation

solutions [24]. Another factor to be consider is

preoperative pain. Some studies demonstrated

that preoperative pain is a strong predictor of

postoperative pain [1,22,24]. In this systematic

review only four studies included patients free

of symptoms [24,25,27,29]. Therefore, future

studies assessing pain should include patients

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Table IV - Quality of evidence and strength of recommendations of the selected studies (GRADE)

Certainty assessment N° of participants or

Events/total Absolute or relative eﬀects (95% CI) Overall certainty

N° of

datasets Study design Risk of bias Inconsistency Indirectness Imprecision Other consid-

erations Intervention Comparator

AH-Plus vs. ZOE-based (8 hours)

1 RCT SeriousaNot serious Not serious SeriousbNone 33 33 No diﬀerence between groups ⊕⊕◯◯

LOW

AH-Plus vs. ZOE-based (24 hours)

2 RCT SeriousaNot serious Not serious SeriousbNone 53 53 No diﬀerence between groups ⊕⊕◯◯

LOW

AH-Plus vs. ZOE-based (48 hours)

2 RCT SeriousaNot serious Not serious SeriousbNone 53 53 No diﬀerence between groups ⊕⊕◯◯

LOW

AH-Plus vs. ZOE-based (72 hours)

1 RCT Not serious Not serious Not serious SeriousbNone 20 20 No diﬀerence between groups ⊕⊕⊕◯

MODERATE

AH-Plus vs. Calcium silicate-based (6 hours) - Continuous data

2 RCT Not serious Not serious Not serious SeriousbNone 52 52 No diﬀerence between groups MD: -0.16 [-0.96, 0.64] ⊕⊕⊕◯

MODERATE

AH-Plus vs. Calcium silicate-based (8 hours) - Continuous data

1 RCT Not serious Not serious Not serious SeriousbNone 13 13 No diﬀerence between groups ⊕⊕⊕◯

MODERATE

AH-Plus vs. Calcium silicate-based (12 hours) - Continuous data

2 RCT Not serious Not serious Not serious SeriousbNone 52 52 No diﬀerence between groups MD: 0.10 [-0.63, 0.82] ⊕⊕⊕◯

MODERATE

AH-Plus vs. Calcium silicate-based (24 hours) - Continuous data

5 RCT Not serious† Not serious Not serious SeriousbNone 156 158 No diﬀerence between groups MD: -0.05 [-0.13, 0.03] ⊕⊕⊕◯

MODERATE

AH-Plus vs. Calcium silicate-based (48 hours) - Continuous data

2 RCT Not serious Not serious¥ Not serious SeriousbNone 89 89 No diﬀerence between groups MD: 0.19 [-0.04, 0.42] ⊕⊕⊕◯

MODERATE

AH-Plus vs. Calcium silicate-based (72 hours) - Continuous data

2 RCT Not serious† Not serious Not serious SeriousbNone 54 56 No diﬀerence between groups MD: 0.00 [-0.00, 0.00] ⊕⊕⊕◯

MODERATE

AH-Plus vs. Calcium silicate-based (96 hours) - Continuous data

1 RCT SeriousaNot serious Not serious SeriousbNone 15 17 No diﬀerence between groups* ⊕⊕◯◯

LOW

AH-Plus vs. Calcium silicate-based (120 hours) - Continuous data

CI = conﬁdence interval; MD = mean diﬀerence; RR = relative risk; aDatasets provide results with risk of bias for some criteria, and likely to seriously alter the results; bLimited amount of data included in the

synthesis (number of subjects evaluated less than the threshold suggested by GRADE of 400); c

2 value greater than 50% (P<0.05); †The subgroup test showed that the study with a high risk of bias did not

aﬀect the direction or signiﬁcance of the eﬀect; therefore, it was kept in the synthesis and it was considered that the evidence was not aﬀected for this topic; ¥Since the imprecision item would be aﬀected

anyway, it was opted to exclude the study by Shimetal. [32] and to make the evidence more consistent. ⊕◯◯◯ = Very low; ⊕⊕◯◯ = Low; ⊕⊕⊕◯ = Moderate.

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Certainty assessment N° of participants or

Events/total Absolute or relative eﬀects (95% CI) Overall certainty

N° of

datasets Study design Risk of bias Inconsistency Indirectness Imprecision Other consid-

erations Intervention Comparator

1 RCT SeriousaNot serious Not serious SeriousbNone 15 17 No diﬀerence between groups ⊕⊕◯◯

LOW

AH-Plus vs. Calcium silicate-based (144 hours) - Continuous data

1 RCT SeriousaNot serious Not serious SeriousbNone 15 17 No diﬀerence between groups ⊕⊕◯◯

LOW

AH-Plus vs. Calcium silicate-based (168 hours) - Continuous data

2 RCT SeriousaNot serious Not serious SeriousbNone 28 30 No diﬀerence between groups ⊕⊕◯◯

LOW

AH-Plus vs. Calcium silicate-based (24 hours) - Binary data

4 RCT SeriousaSeriouscNot serious SeriousbNone 37/143 30/140 No diﬀerence between groups RR: 1.14 [0.45, 2.89] ⊕◯◯◯

VERY LOW

AH-Plus vs. Calcium silicate-based (48 hours) - Binary data

2 RCT SeriousaNot serious Not serious SeriousbNone 2/30 7/30 No diﬀerence between groups RR: 0.29 [0.07, 1.25] ⊕⊕◯◯

LOW

AH-Plus vs. Calcium silicate-based (72 hours) - Binary data

3 RCT SeriousaNot serious Not serious SeriousbNone 13/123 12/120 No diﬀerence between groups RR: 1.03 [0.36, 2.93] ⊕⊕◯◯

LOW

AH-Plus vs. Calcium silicate-based (168 hours) - Binary data

2 RCT Not serious Not serious Not serious SeriousbNone 3/103 6/100 No diﬀerence between groups ⊕⊕⊕◯

MODERATE

AH-Plus vs. Ca(OH)2-based (8 hours) - Continuous data

1 RCT SeriousaNot serious Not serious SeriousbNone 33 33 No diﬀerence between groups ⊕⊕◯◯

LOW

AH-Plus vs. Ca(OH)2-based (24 hours) - Continuous data

1 RCT SeriousaNot serious Not serious SeriousbNone 33 33 No diﬀerence between groups ⊕⊕◯◯

LOW

AH-Plus vs. Ca(OH)2-based (48 hours) - Continuous data

1 RCT SeriousaNot serious Not serious SeriousbNone 33 33 No diﬀerence between groups ⊕⊕◯◯

LOW

synthesis (number of subjects evaluated less than the threshold suggested by GRADE of 400); c

2 value greater than 50% (P<0.05); †The subgroup test showed that the study with a high risk of bias did not

anyway, it was opted to exclude the study by Shimetal. [32] and to make the evidence more consistent. ⊕◯◯◯ = Very low; ⊕⊕◯◯ = Low; ⊕⊕⊕◯ = Moderate.

Table IV - Continued...

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

without preoperative pain, since it may be a

confounding factor in the analysis.

The authors utilized the Cochrane

Collaboration tool for assessing risk of bias -

RoB2. Through this tool, they evaluated the

randomization process, deviations from the

intended intervention, missing outcome data,

measurement of the outcome, and selection of

the reported result. The domain with the most

signicant limitations was the randomization

process. Randomized clinical trials are considered

the gold standard among all investigation

methods, as they are capable of producing direct

scientic evidence with a lower probability of error

for clarifying a cause-effect relationship between

two events. In terms of risk of bias, nine studies

had a low RoB [22-30], two were judged to be

at some concerns in at least one domain [32,33],

and one was considered to have a high RoB [31].

A correct randomization process ensures that no

pattern exists between the assignment of subjects

into groups and in any characteristics of the

subjects. Every subject will be similar to those

assigned to either the treatment or control group.

Allocation concealment, in which the operator

cannot identify which group the patient will be

placed into, should also be given importance.

In relation to selection bias, three studies

presented an unclear randomization process;

allocation concealment was not informed [31,33].

No attrition bias was observed due to missing

data. Some authors acknowledged the missing

data and reported the reasons; however, there

was no substantial loss of study participants

without an imbalanced attrition between the

groups. Another relevant aspect of risk of bias is

the blinding of participants, personnel, operator,

and examiners in relation to assessing treatment

and outcome as well as avoiding performance

bias. The blinding of participants and personnel

was performed in most of studies [22-30,32].

Blinding of the operator was not performed in

all studies due to the color and consistency of

the sealers. Thus, being aware that operator

blindness is not always possible, examiner

masking should be considered a minimum.

Blind outcome assessment was performed in ve

studies [22,23,26,28,30]. Selective reporting was

performed in all studies; their limitations were

reported.

Although this systematic review followed a

rigorous methodology and attempted to reduce

all biases by following strict criteria, its ndings

should be viewed considering some limitations.

Variations of the visual analog scale for pain

assessment were used in different studies.

Additionally, postoperative pain analysis was

conducted at different time intervals. To address

this variability, all scales were resized to a

1–10 scale, but it is unsure to precise if this could

have relevance in the analysis. Regarding time,

the meta-analyses were grouped according to

this variable. Another limitation concerns the

language in which the article was written. Articles

written in English, Portuguese, and Spanish

were selected. Only publications written in other

languages were excluded due to the inability

to access them in full and extract complete

data. In future studies it is recommend using

standardized scales for which there is an overall

consensus.

Although efforts were made to retrieve all

relevant data, publication bias could not be ruled

out. Moreover, the unclear RoB for some of the

included studies could not be veried because

of the authors’ non-response. Therefore, the

ndings of the present systematic review need

to be conrmed by further well-designed studies.

CONCLUSIONS

The quality of evidence supporting

the relationship between root canal sealer

composition and postoperative pain varied from

moderate to very low. There was no signicant

difference between AH-Plus and calcium silicate-

based sealers in the occurrence of postoperative

pain. Further RCTs with high methodological

evidence are needed to assess postoperative

pain with other sealers. Sealer extrusion is also a

variable that requires further clinical evaluation.

Future well-designed RCTs should be performed

to evaluate the inuence of sealer extrusion on

postoperative pain by using a comparative group

without sealer extrusion.

Author’s Contributions

VGM: Conceptualization, Methodology:

eletronic search, studies selection, data extraction,

tables, writing of the manuscript; Validation,

Formal Analysis, Investigation, Resources,

Data Curation. SRSM: Conceptualization,

Methodology: eletronic search, studies selection,

data extraction, tables, gures; Writing – Original

Draft Preparation, Writing – Review & Editing,

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Software: GRADE, Risk of Bias; Validation,

Formal Analysis, Investigation, Resources, Data

Curation. GAMV: Software: GRADE and Risk of

Bias, Validation, Formal Analysis, Data Curation.

LAAA: Writing – Review & Editing, Visualization

of the nal Draft. LSA: Conceptualization, Writing

– Review & Editing, Visualization, Supervision,

Project Administration, Funding Acquisition.

Conict of Interest

The authors deny any conicts of interest

related to this study. The manuscript is original

and has not been published previously, nor is

under consideration elsewhere.

Funding

The work was supported by individual

scholarships (FAPERJ - Fundação de Amparo

à Pesquisa do Estado do Rio de Janeiro

[#E- 26/010.100995/2018; #E-26/202.805/2019;

#E-26/010.002195/2019], CNPQ (Conselho

Nacional de Desenvolvimento Científico e

Tecnológico). This study was also nanced in

part by the Coordenação de Aperfeiçoamento

de Pessoal de Nível Superior - Brasil (CAPES) -

Finance Code 001.

Regulatory Statement

This systematic review was conducted

through a search strategy in electronic databases.

The search was restricted to publications in

peer-reviewed journals, dissertations or theses,

in which approval for ethics committee were

obtained in their original work.

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Leonardo dos Santos Antunes

(Corresponding address)

Universidade Federal Fluminense, Faculdade de Odontologia de Nova Friburgo, Departamento

de Formação Especíca, Nova Friburgo, RJ, Brazil.

Email: leonardoantunes@id.uff.br

Date submitted: 2023 Sept 22

Accept submission: 2024 Mar 20

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Appendix 1. Studies excluded in the full-text analyses with reasons

Author, year Reason for exclusion Indexing in databases (DOI)/ INSS

1 Thakur, 2013

No RCTs

10.4103/0972-0707.120944

2 Shashirekha, 2018 10.4103/JCD.JCD_224_18

3 Yu, 2021 10.1007/s00784-021-03814-x

4 Alacam, 1985

AH-Plus not tested

10.1016/S0099-2399(85)80233-8

5 Goreva, 2004 15111950

6 Sadaf, 2014 25598754

7 Sharma, 2019 23952822

8 Javidi, 2020 10.30476/DENTJODS.2020.83231.1041

9 Nabi, 2020 15509702

10 Sadaf, 2021 10.9734/jpri/2021/v33i42A32418

11 NCT04935736 -

12 NCT03874949 -

13 Wang, 2003

No english, portuguese or spanish

version

10067248

14 Chen, 2006 16718852

15 Tang, 2009 10.3969/j.issn.1673-8225-2009.29.040

16 Xu, 2013 10.3724/SP.J.1008.2013.01029

17 Shu, 2018 10.19439/j.sjos.2018.06.017

18 CTRI / 2021/04/032815

Not ﬁnished

19 NCT03732170 -

20 CTRI/2019/02/017745 -

21 CTRI/2018/10/015919 -

22 NCT04228913 No author reply -

23 NCT02981693 -

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Appendix 2. Forest plots of postoperative pain between AH Plus vs Calcium

silicate-based sealers groups (6, 12, 24, 48, and 72 hours)

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Appendix 2. Continued...

Braz Dent Sci 2024 Jan/Mar;27 (1): e4060

Moraes et al.

Influence of root canal sealer composition on postoperative pain after endodontic treatment of permanent teeth: a systematic review and meta-analyses

Moraes et al. Inﬂuence of root canal sealer composition on postoperative

pain after endodontic treatment of permanent teeth: a

systematic review and meta-analyses

Appendix 3. Forest plots of the relative risk (RR) for postoperative pain between

AH Plus vs Calcium silicate-based sealers groups (24, 48, and 72 hours)