Five-year clinical outcomes of root canal treatment using a calcium silicate–based sealer in teeth with apical periodontitis: a retrospective cohort study

OBJECTIVE: Hydraulic calcium silicate-based sealers (CSBSs) are increasingly used in endodontics, but evidence on their long-term clinical effectiveness remains limited. This retrospective study evaluated the 5-year outcomes of primary root canal treatments and retreatments performed with a CSBS in teeth with symptomatic apical periodontitis. MATERIALS AND METHODS: The sample consisted of 637 teeth with symptomatic apical periodontitis treated by a single experienced operator using a premixed CSBS (CeraSeal; Meta Biomed Co., Cheongju, South Korea) with the cold hydraulic condensation technique (CHC). Data were retrospectively collected from clinical charts and radiographic archives. Preoperative variables included sex, systemic health, tooth type, arch location, lesion size, pulpal diagnosis, sinus tract, and preoperative small perforation. Intraoperative factors comprised intracanal medication, apical diameter, obturation length, and sealer extrusion. Postoperative information included the type of coronal restoration. Follow-up evaluations were based on available radiographs and clinical notes at 1, 2, 3, 4, and 5 years. Outcomes were classified according to strict criteria (absence of symptoms and complete radiographic resolution) and loose criteria (absence of symptoms with complete or partial healing). Prognostic factors were investigated using bivariate associations and multivariate logistic regression models. RESULTS: Strict success rates increased progressively (80.2% at 1 year, 85.7% at 2 years, 86.8% at 3 years, 88.2% at 4 years, and 87.67% at 5 years). Loose success remained consistently high (99.2% at 1 year; 90.7% at 4 years, and 87.67% at 5 years). Higher baseline periapical index (PAI) scores significantly reduced odds of strict success at 2, 3, 4 years. Other factors, including age, sex, tooth type, treatment type, extrusion, and restoration, were not significant. CONCLUSIONS: CSBSs demonstrated favorable long-term outcomes. Preoperative lesion severity was the main prognostic factor, while demographic and procedural variables showed limited influence on long-term success. CLINICAL RELEVANCE: This study supports the long-term clinical reliability of CSBSs used with CHC in teeth with apical periodontitis. Preoperative lesion severity remains the primary prognostic factor influencing periapical healing over time.