Title	Sealer Extrusion Results in a Higher Risk of a Non-Healing Endodontic Outcome Compared to No Extrusion
Clinical Question	For patients receiving initial root canal treatment, does sealer extrusion have a negative impact on the success rate compared to root canal treatment with no sealer extrusion?
Clinical Bottom Line	During primary or secondary root canal treatment, it is best to keep sealer within the root because extrusion increases the risk of delayed or poor healing.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 31449355 Aminoshariae/2019 6 studies/3,328 patients Meta-Analysis Key results Aminoshariae states that sealer extrusion has a 32% higher risk of contributing to a non-healing outcome than no extrusion (risk ratio 1.32 (95% confidence interval, 1.12-1.54; p < 0.05). The meta-analysis was based on 6 cohort studies with a low heterogeneity between studies I^2 = 29%.
Evidence Search	(sealer[All Fields] AND extrusion[All Fields]) AND outcome[All Fields]
Comments on The Evidence	Two independent reviewers performed a thorough literature search of cohort studies found within scientific peer reviewed journals dating 1960 to February 2019. Six articles met the inclusion criteria and were further analyzed and used in a meta-analysis. The checklist for Meta-analysis of Observations Studies (MOOSE) was utilized. The New Castle-Ottawa Quality Assessment Form for Cohort Studies was used to assess risk of bias. Most of the included articles had a follow-up period that ranged from 2 to 6 years; however, one study only observed healing after 1 year in a portion of the patient pool. This review groups primary and secondary endodontic treatment together. There is not enough available literature to evaluate outcome as it relates to sealer extrusion within these two different treatment modalities. The main weakness of this review is that different sealers were used between the included studies. Out of the six articles, four types of sealers were used with varying chemical properties and biocompatibility. However, despite different types of sealers, the results were still consistent. None of the articles reported on the amount of extruded sealer or the size of radiopacity caused by extruded sealer. Quantifying sealer extrusion would be interesting to note for future studies because large amounts of sealer may have a more deleterious effect on outcome compared to smaller “sealer puffs”. All included studies utilized 2D radiographs to visualize sealer extrusion and to evaluate outcome. Future studies that use cone beam computed tomography would provide a more accurate assessment of radiographic healing in all dimensions and help quantify extruded obturation material.
Applicability	This review shows that sealer extrusion can have a negative impact on healing outcome after primary and secondary root canal treatment, emphasizing the importance of accurate length control during treatment. Apex locators and intraoperative radiographs should be utilized routinely during root canal treatment to ensure that obturation materials remain inside the root and not in the periapical tissues. The radiographic esthetic “sealer puff” provides no advantage to outcome and according to this review can hinder complete healing.
Specialty	(Endodontics) (General Dentistry)
Keywords	Root canal treatment, sealer extrusion, outcome.
ID#	3406
Date of submission	11/26/2019
E-mail	jlovellou@gmail.com
Author	John Lovell
Co-author(s)	Lucas Sheppard
Co-author(s) e-mail	llsheppard42@gmail.com
Faculty mentor	Allen Pratt, DMD
Faculty mentor e-mail	allen.m.pratt2.mil@mail.mil
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available