Does a bioceramic sealer reduce pain after root canal treatment compared with AH Plus?

3.4. PIOS 3: POP and Obturation Protocols

Other comparisons involving zinc oxide–eugenol sealers, calcium silicate-based sealers, and calcium hydroxide-based sealers similarly showed no clinically significant differences in post-operative pain outcomes. The data does not support a clinically consistent difference in post-operative pain between bioceramic/calcium silicate-based sealers and resin-based sealers, especially at delayed follow-up periods. Some reviews reported lower early pain with bioceramic or calcium silicate-based sealers, but these findings were not uniform. The certainty of evidence ranged from low to moderate, and the findings were frequently limited by risk of bias, small sample sizes, and variability in treatment protocols.

Post-Operative Pain After Endodontic Instrumentation, Irrigation and Obturation: An Umbrella Review of Systematic Reviews Published from 2016 to 2025. © 2026 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

3.4. PIOS 3: POP and Obturation Protocols

A total of eight systematic reviews assessed the association between obturation strategies and post-operative pain, including comparisons between different sealer types and obturation materials. Detailed results are summarized in Table 4. Most systematic reviews focused on comparisons between bioceramic sealers and epoxy resin-based sealers. The majority of the evidence suggested no significant differences in post-operative pain between different sealer types, particularly in the delayed post-operative period (3–7 days). Some reviews reported slightly lower pain levels with bioceramic sealers during the first 24 h, although these differences were not consistently observed across studies. The most recent review also included bioactive glass-based sealers and reported no significant difference in pain occurrence at 24 h, 48 h, and 7 days compared with epoxy resin-based sealers. Other comparisons involving zinc oxide–eugenol sealers, calcium silicate-based sealers, and calcium hydroxide-based sealers similarly showed no clinically significant differences in post-operative pain outcomes.

Post-Operative Pain After Endodontic Instrumentation, Irrigation and Obturation: An Umbrella Review of Systematic Reviews Published from 2016 to 2025. © 2026 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Clinical relevance

Postoperative pain after root canal obturation was minimal with both AH Plus and EndoSequence BC sealers. Minor differences in pain intensity were observed during the early postoperative period, with a slightly faster reduction in pain reported for EndoSequence BC, and no differences in pain risk or impact on quality of life.

Postoperative pain and quality of life after the use of different endodontic sealers in asymptomatic molars: a randomized clinical trial. © The Author(s) 2026. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

5. Conclusions

Within the above-mentioned limits of this umbrella review, lower sodium hypochlorite concentrations, irrigant activation protocols and intracanal cryotherapy were the procedural factors most associated with reduced short-term post-operative pain after non-surgical root canal treatment. Instrumentation protocols may also influence post-operative pain; however, reviews comparing rotary, reciprocating, and manual systems were heterogeneous, and no definitive superiority of a single kinematic approach can be established. No clinically relevant differences between bioceramic/calcium silicate-based sealers and resin-based sealers were observed, but the very high overlap of primary studies in this domain limits interpretation as independent confirmation. These findings should be interpreted as a trend from partially redundant secondary evidence rather than as independent confirmation. Future high-quality systematic reviews and adequately powered clinical studies, using standardized pain outcomes, clearly reported baseline diagnoses, and consistent follow-up, are needed.

Post-Operative Pain After Endodontic Instrumentation, Irrigation and Obturation: An Umbrella Review of Systematic Reviews Published from 2016 to 2025. © 2026 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Abstract

NaOCl concentrations, irrigant activation, and intracanal cryotherapy were repeatedly reported as being associated with reduced short-term post-operative pain. For instrumentation, most reviews reported lower pain with rotary systems, but two studies found no difference or favored reciprocating kinematics. Apical patency did not appear to increase pain and foraminal enlargement may increase early pain. No clinically consistent differences were observed between bioceramic/calcium silicate-based and resin-based sealers, although calcium silicate sealers seem to support periapical healing. However, the certainty of these findings was limited by heterogeneity, methodological weaknesses, and overlap among primary studies. Methodological limitations were identified across reviews, mainly related to no protocol registration (n = 4), incomplete reporting of excluded studies with justification (n = 11), limited assessment of publication bias, and poor reporting of funding sources for primary studies. Conclusions: Based on current evidence, irrigation, instrumentation, and obturation procedures may influence short-term post-operative pain.

Post-Operative Pain After Endodontic Instrumentation, Irrigation and Obturation: An Umbrella Review of Systematic Reviews Published from 2016 to 2025. © 2026 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).